Hyperarousal and sleep reactivity in insomnia: current insights

"When I Sleep Poorly, It Impacts Everything": An Exploratory Qualitative Investigation of Stress and Sleep in Junior Endurance Athletes

On their journeys toward senior athletic status, junior endurance athletes are faced with a multitude of stressors. How athletes react to stressors plays a vital part in effective adaptation to the demanding, ever-changing athletic environment. Sleep, the most valued recovery strategy available to athletes, has the potential to influence and balance athletic stress, and enable optimal functioning. However, sleep is sensitive to disturbances by stress, which is described by the concept of sleep reactivity. Among athletes, poor sleep quality is frequently reported, but our understanding of the associations between stress and sleep in junior athletes is currently incomplete. The present study therefore investigated the themes of stress and sleep, and the associations between these variables with the use of in-depth semi-structured interviews in six junior endurance athletes (three men and three women, mean age 17.7 ± 0.5 years). Data was analyzed qualitatively based on the Grounded Theory. The qualitative material was supplemented with quantitative data on subjective sleep quality (Pittsburg Sleep Quality Index), sleep reactivity (Ford Insomnia Response to Stress Test), and mental strain (visual analog scale). The main results showed that stress could be differentiated into relevant stressors (encompassing poor performance, uncertainty in relation to training, school, daily hassles, and sleep) and reactions to stress (with sub-categories facilitative and maladaptive). Sleep could be differentiated into sleep benefits (encompassing energy levels and athletic functioning) and sleep quality (with sub-categories satisfactory and inadequate). All athletes identified relevant stressors, and all athletes were aware of the benefits of sleep for athletic functioning. However, athletes formed two distinctive categories based on the interactions between stress and sleep: three exhibited facilitative reactions to stress and good sleep quality, as well as low sleep reactivity, and low mental strain. The remaining participants exhibited maladaptive reactions to stress and poor sleep quality, as well as high sleep reactivity and high mental strain. Conceptualizing sleep quality based on the evaluation of stressors, reactions to stress, degree of mental strain, and the propensity to stress-related sleep disturbance may offer a plausible explanation for why the occurrence of stressors leads to poor sleep quality in some athletes, but not others.

The association of insomnia disorder characterised by objective short sleep duration with hypertension, diabetes and body mass index: A systematic review and meta-analysis

Insomnia disorder with objective short sleep duration (less than 6 h of objective sleep or sleep efficiency less than 85%) has been considered as a biologically severe subtype of insomnia associated with a higher risk of cardiometabolic disease morbidity. This systematic review and meta-analysis firstly compared insomnia disorder with objective short and normal sleep duration, and subsequently, objective short sleep duration with and without insomnia disorder, and their associations with hypertension, type 2 diabetes and body mass index. A systematic search of five databases yielded 2345 non-duplicated articles, of which 11 individual studies were used for the qualitative review and 10 individual studies for the meta-analysis. The sample size varied from 30 to 4994 participants. A higher risk of hypertension (RR 1.54, 95% CI: [1.30; 1.82] p < 0.0001) and type 2 diabetes (RR 1.63 [1.37; 1.94], p < 0.0001) was associated with insomnia disorder with objective short sleep compared to normal sleep duration, but not for body mass index. Comparisons between insomnia disorder with objective short sleep and objective short sleep without insomnia disorder showed no significant differences. However, the majority of these studies were cross-sectional, and there is a need for more cohort study data.

The Association between Symptoms of Nomophobia, Insomnia and Food Addiction among Young Adults: Findings of an Exploratory Cross-Sectional Survey

No previous research has examined the association between symptoms of nomophobia and food addiction. Similarly, only a few studies have examined the association between nomophobia and symptoms of insomnia. This exploratory study utilized an online self-administered, structured questionnaire that included: basic sociodemographic and anthropometrics; the nomophobia questionnaire (NMP-Q); the insomnia severity index (ISI); and the Yale Food Addiction Scale (YFAS) in a convenience sample of young adults (18-35 years) in Bahrain (n = 654), 304 (46%) males and 350 (54%) females. Symptoms of severe nomophobia, moderate-severe insomnia, and food addiction were more common among female participants both for each disorder separately and in combination; however, differences did not reach statistical significance. For severe nomophobia, the rate for females was 76 (21.7%) and for males was 57 (18.8%) p = 0.9. For moderate-severe insomnia, the rate for females was 56 (16%) and for males was 36 (11.84%) p = 0.1. For food addiction, the rate for females was 71 (20.29%) and for males was 53 (17.43%) p = 0.3. A statistically significant association was present between nomophobia and insomnia r = 0.60, p < 0.001. No association was found between nomophobia and food addiction. Nomophobia is very common in young adults, particularly in females; nomophobia is associated with insomnia but not with food addiction.

Harnessing the Spatial Foundation of Mind in Breaking Vicious Cycles in Anxiety, Insomnia, and Depression: The Future of Virtual Reality Therapy Applications

Mental Illnesses, particularly anxiety, insomnia, and depression often involve vicious cycles which are self-perpetuating and can trap one into a more chronic state. For example in the case of insomnia, sympathetic overactivity, intrusive thoughts, and emotional instability due to sleep loss can perpetuate further sleep loss the next night and so on. In this article, we put forward a perspective on breaking these vicious cycles based on preeminent theories in global and spatial cognition, that the foundation of the conscious mind is a spatial coordinate system. Based on this we discuss the potential and future of virtual reality therapeutic applications which utilize massive virtual spaces along with biofeedback designed to help break perpetual cycles in depression, anxiety, and insomnia. "Massive spaces" are those which are truly expansive such as when looking to the clear night sky. These virtual realities may take the form of a night sky, fantastical cosmic scenes, or other scenes such as mountain tops. We also hope to inspire research into such a spatial foundation of mind, use of perceived massive spaces for therapy, and the integration of biofeedback into virtual therapies.

Pediatric Insomnia

Insomnia is the most common sleep disorder among all ages; unfortunately, however, child and adolescent insomnia is infrequently addressed. Given the importance of adequate sleep for proper brain development, pediatric populations are particularly vulnerable to the negative effects of insomnia. Therefore, proper clinical assessment and treatment of pediatric insomnia is crucial. This article is the result of a comprehensive literature review and serves as a guide to the disorder and how it presents differently across child development.

Insomnia Symptoms in the General Population During the COVID-19 Pandemic

This empirical study aims to investigate factors associated with insomnia symptoms during the COVID-19 pandemic in 4,921 Norwegian adults. Participants were queried across two time-points, between March 31^st and April the 7th 2020, and between June 22nd and July 13th, 2020. Relevant risk factors and psychological correlates at the first time-point and insomnia symptoms were measured 3 months later, allowing for the investigation of concurrent associations as well as associations across time. Insomnia symptoms were measured with the Bergen Insomnia Scale. The results revealed that individuals reported higher mean levels of insomnia symptoms during the COVID-19 lockdown, compared to pre-pandemic surveys from 2008 (p < 0.0001, Cohen's d = 0.29). Individuals who predominantly socially distanced reported higher mean levels of insomnia symptoms than those who did not predominantly distance. Females, individuals with lower education levels, individuals who had lost their job, and individuals who declared having been diagnosed with an unspecified pre-existing psychiatric disorder reported the most symptoms. The regression model (R² = 0.44) showed that physical exercise, was associated with less symptoms of insomnia. Symptoms of health Anxiety, symptoms of depression, unhelpful coping strategies, worry about job and economy, and older age were all associated with higher levels of insomnia symptoms. These findings highlight particularly vulnerable subgroups, as well as providing clinicians with key areas of intervention to help individuals suffering from insomnia symptoms.

Prevalence and correlates of poor sleep quality in chronic liver disease patients

INTRODUCTION

Previously done studies have shown that 39.6%-81% of subjects with chronic liver disease (CLD) report poor sleep quality and 42% experience insomnia. However, despite the high prevalence of insomnia and poor sleep quality in this group of patients, literature is scanty. In addition, previous studies have not ruled out subjects with restless legs syndrome, which is seen in a sizable number of subjects having CLD.

MATERIAL AND METHODS

Adult patients with a clinical diagnosis of CLD were included after excluding potential confounders. The etiology of CLD was investigated. The severity of liver disease was assessed and graded as Child-Turcotte-Pugh (CTP) class A, B or C; model for end-stage liver disease (MELD) score and as the presence of compensated or decompensated liver disease. Acute on chronic liver failure was also defined as per APASL criteria. For the present study, subjects having a score greater than 14 on insomnia severity index along with clinical diagnosis (DSM-5) were considered as having insomnia. Depression was diagnosed using a patient health questionnaire (PHQ-9) along with clinical criteria following DSM-5. Sleep quality was assessed by the Pittsburg sleep quality index - Hindi version. RLS was diagnosed on clinical interview and examination. The severity of RLS was assessed using international RLS severity rating scales.

RESULTS

This cross-sectional study included 131 subjects. This sample had a predominance of males (78.6%), the average age of subjects was 48.70+12.31 years and 98.5% of subjects had decompensated liver disease. 54.2% had a history of alcohol use disorder and 45% had a history of nicotine use disorder. The prevalence of hepatitis B and C infection was 16.8% and 23.7%, respectively. Acute on chronic liver failure was observed in 22.9% of subjects. 19.8% of subjects had acute kidney injury. Poor sleep quality was reported by 37.4% of subjects in this study which was higher than population prevalence (p<0.001). Subjects with poor sleep quality had a higher proportion of insomnia, RLS, and depression. 19.8% of subjects reported insomnia in the present study and depressive symptoms were more severe among subjects with insomnia. RLS was reported by 19.1% of subjects and 2.3% had a positive family history of RLS. However, there was no difference in sleep quality and insomnia in patients with or without RLS.

CONCLUSION

The present study shows that insomnia and poor sleep quality are more prevalent among patients with CLD. Sleep disturbance is associated with depressive symptoms and can worsen the quality of life.

Higher Levels of Stress Are Associated With a Significant Symptom Burden in Oncology Outpatients Receiving Chemotherapy

CONTEXT

A cancer diagnosis and associated treatments, as well as the uncertainty of the disease course, are stressful experiences for most patients. However, little information is available on the relationship between stress and symptom burden.

OBJECTIVES

The study purpose was to evaluate for differences in the severity of fatigue, lack of energy, sleep disturbance, and cognitive function, among three groups of patients with distinct stress profiles.

METHODS

Patients receiving chemotherapy (n = 957) completed measures of general, cancer-specific, and cumulative life stress and symptom inventories. Latent profile analysis was used to identify subgroups of patients with distinct stress profiles.

RESULTS

Three distinct subgroups of patients were identified (i.e., stressed [39.3%], normative [54.3%], resilient [5.7%]). For cognitive function, significant differences were found among the latent classes (stressed < normative < resilient). For both sleep disturbance and morning and evening fatigue, compared to the normative and resilient classes, the stressed class reported higher severity scores. Compared to the normative and resilient classes, the stressed class reported low levels of morning energy. Compared to the normative class, the stressed class reported lower levels of evening energy.

CONCLUSIONS

Consistent with our a priori hypothesis, patients in the stressed class had the highest symptom severity scores for all four symptoms and all these scores were above the clinically meaningful cutoffs for the various instruments.

Persistent Short Sleep from Childhood to Adolescence: Child, Parent and Peer Predictors

PURPOSE

Many children have periods when they sleep too little, with widely recognized detrimental effects. Less is known about persistent short sleep during childhood. Therefore, the present study aimed to investigate the prevalence of persistent short sleep in school-aged children and identify a set of child, parent, and peer predictors thereof.

PARTICIPANTS AND METHODS

Objectively measured sleep duration (hip-held accelerometer) was biennially assessed in a community sample followed from 6 to 14 years (n=801). A latent profile analysis was applied to assess whether a subgroup of children slept consistently short across time and predictors of persistent short sleep were determined through regression analysis.

RESULTS

A subgroup of children (n=160; 20.2%) was identified as having persistent short sleep across time. Temperamental negative affectivity (β=0.08; 95% CI=0.01, 0.15; p=0.03) and low observer-assessed parental emotional availability (β=-.09; 95% CI=-.18, -.01; p=0.04) predicted membership to that group. Teacher ratings of victimization from bullying were not associated with persistent short sleep (β=0.01; 95% CI: -.10, 11; p=0.88).

CONCLUSION

High child temperamental negative affectivity and low parental emotional availability may be involved in the development of persistent short sleep through childhood.

Worry and insomnia as risk factors for depression during initial stages of COVID-19 pandemic in India

The biggest nationwide COVID-19 pandemic lockdown worldwide was enforced in India for an initial period of 21-days. Emerging evidence suggests that pandemic situations and associated lockdowns have an adverse impact on sleep and mental health. However, prediction of sleep health from sociodemographic characteristics and the public’s worry during the initial stages of the COVID-19 pandemic has not been extensively explored so far. It’s also unclear whether sleep outcomes mediate the association between worry and mental health during pandemic situations. A web-survey (N = 391) on sociodemographic characteristics, COVID-19 related worry, sleep health (insomnia and daytime sleepiness), and depression was conducted during the initial 21-days of the COVID-19 stringent lockdown in India. Multiple regression analyses showed that variables, including sex, age, income level, and worry score, contributed to the significant regression equation for insomnia but not for daytime sleepiness. Specifically, the female, younger, lower income, and highly worried populations contributed significantly more than the male, elderly, higher income, and less worried populations, respectively, to the prediction of insomnia. Mediation analyses showed that insomnia, but not daytime sleepiness, fully mediated the relationship between worry score and severity of depressive symptoms. We provide evidence that the female, younger, lower income, and worried populations may be at higher risk for insomnia during pandemic situations. Current evidence gives hope that improving sleep may reduce depressive symptoms during a pandemic situation. This underscores the importance of the implementation of effective public health policies in conjunction with strategical responses to the COVID-19 pandemic.

Habitual sleep disturbances and migraine: a Mendelian randomization study

OBJECTIVE

Sleep disturbances are associated with increased risk of migraine, however the extent of shared underlying biology and the direction of causal relationships between these traits is unclear. Delineating causality between sleep patterns and migraine may offer new pathophysiologic insights and inform subsequent intervention studies. Here, we used genetic approaches to test for shared genetic influences between sleep patterns and migraine, and to test whether habitual sleep patterns may be causal risk factors for migraine and vice versa.

METHODS

To quantify genetic overlap, we performed genome-wide genetic correlation analyses using genome-wide association studies of nine sleep traits in the UK Biobank (n ≥ 237,627), and migraine from the International Headache Genetics Consortium (59,674 cases and 316,078 controls). We then tested for potential causal effects between sleep traits and migraine using bidirectional, two-sample Mendelian randomization.

RESULTS

Seven sleep traits demonstrated genetic overlap with migraine, including insomnia symptoms (rg = 0.29, P < 10-31 ) and difficulty awakening (rg = 0.11, P < 10-4 ). Mendelian randomization analyses provided evidence for potential causal effects of difficulty awakening on risk of migraine (OR [95% CI] = 1.37 [1.12-1.68], P = 0.002), and nominal evidence that liability to insomnia symptoms increased the risk of migraine (1.09 [1.02-1.16], P = 0.02). In contrast, there was minimal evidence for an effect of migraine liability on sleep patterns or disturbances.

INTERPRETATION

These data support a shared genetic basis between several sleep traits and migraine, and support potential causal effects of difficulty awakening and insomnia symptoms on migraine risk. Treatment of sleep disturbances may therefore be a promising clinical intervention in the management of migraine.

Mindfulness and Behaviour Therapy for Insomnia: An Assessment of Treatment Effect in a Sleep Disorders Clinic Population with Insomnia

Insomnia is a common major health concern, which causes significant distress and disruption in a person's life. The objective of this paper was to evaluate a 6-week version of Mindfulness-Based Therapy for Insomnia (MBTI) in a sample of people attending a sleep disorders clinic with insomnia, including those with comorbidities. Thirty participants who met the DSM-IV-TR diagnosis of insomnia participated in a 6-week group intervention. Outcome measures were a daily sleep diary and actigraphy during pre-treatment and follow-up, along with subjective sleep outcomes collected at baseline, end-of-treatment, and 3-month follow-up. Trend analyses showed that MBTI was associated with a large decrease in insomnia severity (p < .001), with indications of maintenance of treatment effect. There were significant improvements in objective sleep parameters, including sleep onset latency (p = .005), sleep efficiency (p = .033), and wake after sleep onset (p = .018). Significant improvements in subjective sleep parameters were also observed for sleep efficiency (p = .005) and wake after sleep onset (p < .001). Overall, this study indicated that MBTI can be successfully delivered in a sleep disorders clinic environment, with evidence of treatment effect for both objective and subjective measures of sleep.

Human Responses to Visually Evoked Threat

Vision is the primary sense humans use to evaluate and respond to threats. Understanding the biological underpinnings of the human threat response has been hindered by lack of realistic in-lab threat paradigms. We established an immersive virtual reality (VR) platform to simultaneously measure behavior, physiological state, and neural activity from the human brain using chronically implanted electrodes. Subjects with high anxiety showed increased visual scanning in response to threats as compared to healthy controls. In both healthy and anxious subjects, the amount of scanning behavior correlated with the magnitude of physiological arousal, suggesting that visual scanning behavior is directly linked to internal state. Intracranial electroencephalography (iEEG) recordings from three subjects suggested that high-frequency gamma activity in the insula positively correlates with physiological arousal induced by visual threats and that low-frequency theta activity in the orbitofrontal cortex (OFC) negatively correlates with physiological arousal induced by visual threats. These findings reveal a key role of eye movements and suggest that distinct insula and OFC activation dynamics may be important for detecting and adjusting human stress in response to visually perceived threats.

Poor Sleep Quality and Its Consequences on Mental Health During the COVID-19 Lockdown in Italy

BACKGROUND

Coronavirus disease 2019 (COVID-19) seriously affected the whole of Italy. The extreme virulence and the speed of propagation resulted in restrictions and home confinement. This change was immediately perceived by people who found themselves exposed to feelings of uncertainty, fear, anger, stress, and a drastic change in the diurnal but above all nocturnal lifestyle. For these reasons, we aimed to study the quality of sleep and its connection to distress levels and to evaluate how lifestyle changed in the Italian population during the lockdown.

METHODS

By means of an Internet survey we recruited 6,519 adults during the whole of the COVID-19 lockdown (from March 10-1st phase to May 4-2nd phase). We investigated the sociodemographic and COVID-19-related information and assessed sleep quality using the Medical Outcomes Study-sleep scale (MOS-SS) and mental health with the short form of Depression, Anxiety, and Stress Scales-21 Items (DASS-21). Multiple logistic regression model was used to evaluate the multivariate association between the dependent variable (good sleeper vs. poor sleeper) and all the variables that were significant in the univariate analysis.

RESULTS

A total of 3,562 (55.32%) participants reported poor sleep quality according to the MOS-Sleep Index II score. The multiple binary logistic regression results of poor sleepers revealed several risk factors during the outbreak restrictions: female gender, living in Central Italy, having someone close who died because of COVID-19, markedly changed sleep-wake rhythms characterized by earlier or postponed habitual bedtime, earlier habitual awakening time and reduced number of afternoon naps, and extremely severe levels of stress, anxiety, and depression.

CONCLUSION

This is the first study designed to understand sleep quality and sleep habits during the whole of the lockdown period in the Italian population that provides more than 6,000 participants in a survey developed specifically for the health emergency related to COVID-19. Our study found that more than half of the Italian population had impaired sleep quality and sleep habits due to elevated psychological distress during the COVID-19 lockdown containment measures. A multidisciplinary action should be undertaken in order to plan appropriate responses to the current crisis caused by the lockdown for the COVID-19 outbreak.

Enhanced Vigilance Stability during Daytime in Insomnia Disorder

Central nervous hyperarousal is as a key component of current pathophysiological concepts of chronic insomnia disorder. However, there are still open questions regarding its exact nature and the mechanisms linking hyperarousal to sleep disturbance. Here, we aimed at studying waking state hyperarousal in insomnia by the perspective of resting-state vigilance dynamics. The VIGALL (Vigilance Algorithm Leipzig) algorithm has been developed to investigate resting-state vigilance dynamics, and it revealed, for example, enhanced vigilance stability in depressive patients. We hypothesized that patients with insomnia also show a more stable vigilance regulation. Thirty-four unmedicated patients with chronic insomnia and 25 healthy controls participated in a twenty-minute resting-state electroencephalography (EEG) measurement following a night of polysomnography. Insomnia patients showed enhanced EEG vigilance stability as compared to controls. The pattern of vigilance hyperstability differed from that reported previously in depressive patients. Vigilance hyperstability was also present in insomnia patients showing only mildly reduced sleep efficiency. In this subgroup, vigilance hyperstability correlated with measures of disturbed sleep continuity and arousal. Our data indicate that insomnia disorder is characterized by hyperarousal at night as well as during daytime.

Stress and Symptom Burden in Oncology Patients During the COVID-19 Pandemic

CONTEXT

No information is available on oncology patients' level of stress and symptom burden during the coronavirus disease 2019 (COVID-19) pandemic.

OBJECTIVES

To evaluate for differences in demographic and clinical characteristics, levels of social isolation and loneliness, and the occurrence and severity of common symptoms between oncology patients with low vs. high levels of COVID-19 and cancer-related stress. In addition, to determine which of these characteristics were associated with membership in the high-stressed group.

METHODS

Patients were 18 years and older; had a diagnosis of cancer; and were able to complete an online survey.

RESULTS

Of the 187 patients in this study, 31.6% were categorized in the stressed group (Impact of Event Scale-Revised [score of ≥24]). Stressed group's Impact of Event Scale-Revised score exceeds previous benchmarks in oncology patients and equates with probable post-traumatic stress disorder. In this stressed group, patients reported occurrence rates for depression (71.2%), anxiety (78.0%), sleep disturbance (78.0%), evening fatigue (55.9%), cognitive impairment (91.5%), and pain (75.9%). Symptom severity scores equate with clinically meaningful levels for each symptom.

CONCLUSION

We identified alarmingly high rates of stress and an extraordinarily high symptom burden among patients with cancer, exceeding those previously benchmarked in this population and on par with noncancer patients with post-traumatic stress disorder. Given that the COVID-19 pandemic will likely impact cancer care for an indefinite period, clinicians must exhibit increased vigilance in their assessments of patients' level of stress and symptom burden. Moreover, an increase in referrals to appropriate supportive care resources must be prioritized for high-risk patients.

The association between micronutrient status and sleep quality in patients with depression: a case-control study

PURPOSE

Few previous studies estimated the association between micronutrient status and sleep quality; no previous work was done in patients with depression compared with healthy controls.

METHODS

Using a case-control design, 96 patients with depression were age- and sex-matched with 96 healthy controls. Dietary assessment utilized a standardized questionnaire, and analysis focused comprehensively on 18 micronutrient items. Sleep quality was measured using the Pittsburg Sleep Quality Index (PSQI). Descriptive statistics were used to summarize findings. Logistic regression analysis was used to identify predictors of poor sleep quality.

RESULTS

Patients with depression had a significantly lower sleep quality than controls with PSQI scores of 7.3 ± 2.7 and 5.1 ± 2.5, respectively. The prevalence of poor sleep quality in patients with depression was almost double the prevalence of poor sleep quality in the general population. The micronutrient status of vitamin B12 and Mg successfully predicted sleep quality in healthy controls. However, in patients with depression, micronutrient status failed to predict sleep quality.

CONCLUSIONS

The current research showed that sleep quality was positively associated with Mg intake, and negatively associated with vitamin B12 in healthy adults. For patients with depression in this study sample, sleep quality was not associated with micronutrient intake status. Further research is needed to determine if intake of micronutrients can improve sleep and/or depressive symptoms in patients with depression.

Sex differences in self-report anxiety and sleep quality during COVID-19 stay-at-home orders

BACKGROUND

COVID-19 and home isolation has impacted quality of life, but the perceived impact on anxiety and sleep remains equivocal. The purpose of this study was to assess the impact of COVID-19 and stay-at-home orders on self-report anxiety and sleep quality, with a focus on sex differences. We hypothesized that the COVID-19 pandemic would be associated with increased anxiety and decreased sleep quality, with stronger associations in women.

METHODS

One hundred three participants (61 female, 38 ± 1 years) reported perceived changes in anxiety and sleep quality due to stay-at-home orders during the COVID-19 pandemic and were administered the Spielberger State-Trait Anxiety Inventory (STAI), Pittsburgh Sleep Quality Index (PSQI), and Insomnia Severity Index (ISI). Chi-square and T test analyses were utilized to assess sex differences in reported anxiety and sleep. Analysis of covariance was used to compare the associations between reported impact of COVID-19 and anxiety/sleep parameters.

RESULTS

Women (80.3%) reported higher prevalence of increased general anxiety due to COVID-19 when compared to men (50%; p = 0.001) and elevated STAI state anxiety compared to men (43 ± 1 vs. 38 ± 1 a.u., p = 0.007). Despite these differences in anxiety, the perceived impact of COVID-19 on PSQI was not different between sexes. However, when stratified by perceived changes in anxiety due to COVID-19, participants with higher anxiety responses to COVID-19 had higher ISI compared to those with no perceived changes in anxiety (9 ± 1 vs. 5 ± 1 a.u., p = 0.003). Additionally, participants who reported reduced sleep quality due to COVID-19 reported higher state anxiety (45 ± 1 a.u.) compared to those that perceived no change (36 ± 2 a.u., p = 0.002) or increased (36 ± 2 a.u., p < 0.001) sleep quality.

CONCLUSION

COVID-19 and state-ordered home isolation was associated with higher anxiety and reduced sleep quality, with a stronger association in women with respect to anxiety.

Combined effect of emotional labor and job insecurity on sleep disturbance among customer service workers

Background

Job insecurity and emotional labor are poor job-related factors that are known to cause sleep disturbances in customer service workers. This study investigates the combined effect of emotional labor and job insecurity on sleep disturbance.

Methods

This study used data from the Fifth Korean Working Condition Survey and included 15,147 paid workers who serve customers below 65 years. We re-classified into 6 groups based on whether the degree of emotional labor increased (Rarely/Sometimes/Always) or whether job insecurity (No/Yes) was present. We performed propensity score matching for several covariates and calculated odds ratio (OR) and 95% confidence intervals (CIs) for sleep disturbance by logistic regression models using only matched subjects.

Results

Workers exposed to emotional labor and job insecurity had significantly higher risk for 3 dimensions of sleep disturbance (difficulty falling asleep, waking up repeatedly during the sleep, and waking up with feeling of fatigue) (OR [95% CI]: 1.44 [1.22–1.69], 1.18 [0.99–1.40], 1.52 [1.30–1.79] for emotional labor; and 2.00 [1.75–2.29], 2.20 [1.91–2.53], 1.67 [1.45–1.92] for job insecurity). Compared to those who were exposed to both emotional labor rarely and without job insecurity, when workers had both poor job factors, the OR (95% CI) for sleep disturbance for difficulty falling asleep, waking up repeatedly during the sleep, and waking up with feeling of fatigue were 3.05 (2.42–3.86), 2.89 (2.26–3.69), and 2.60 (2.06–3.29), respectively. The relative excess risk due to Interaction of job insecurity and emotional labor was significant only for difficulty falling asleep, but not the other 2 sleep disturbance dimensions.

Conclusions

Customer service workers suffered from severe sleep disturbances according to the existing degree of emotional labor and job insecurity. The combined effect of both could have an additive influence on serious sleep disturbance among customer service workers.

Changes in resting-state brain connectivity following computerized cognitive behavioral therapy for insomnia in dialysis patients: A pilot study

OBJECTIVE

Insomnia is prevalent among dialysis patients and affects their mortality. Although cognitive behavioral therapy for insomnia (CBTi) is recommended, attending regular face-to-face CBTi sessions is a major challenge for patients. We evaluated the effectiveness of a self-directed computerized CBTi (cCBTi) in dialysis patients, and investigated changes in resting-state brain connectivity and inflammatory cytokines following cCBTi.

METHOD

Thirty-five patients undergoing maintenance hemodialysis or peritoneal dialysis who had insomnia were screened for participation in the study, with 17 participants included in the final analyses. A self-directed cCBTi protocol accessed via tablet computer during dialysis or at home was developed and applied. Information about sleep, anxiety, depression, laboratory data, and resting-state functional magnetic resonance imaging data was obtained 3-5 days before and after cCBTi.

RESULTS

cCBTi improved sleep quality, and this was correlated with increased resting-state brain connectivity between the default-mode network and the premotor/dorsolateral prefrontal cortex. The decrement of interleukin-1β levels were correlated with improved sleep quality and increased brain connectivity after cCBTi.

CONCLUSION

Our pilot study findings suggest that cCBTi is effective for dialysis patients with insomnia, and the therapeutic effects of cCBTi are related to changes in brain functional connectivity and inflammatory cytokines.

Brain mechanisms of insomnia: new perspectives on causes and consequences

While insomnia is the second most common mental disorder, progress in our understanding of underlying neurobiological mechanisms has been limited. The present review addresses the definition and prevalence of insomnia and explores its subjective and objective characteristics across the 24-hour day. Subsequently, the review extensively addresses how the vulnerability to develop insomnia is affected by genetic variants, early life stress, major life events, and brain structure and function. Further supported by the clear mental health risks conveyed by insomnia, the integrated findings suggest that the vulnerability to develop insomnia could rather be found in brain circuits regulating emotion and arousal than in circuits involved in circadian and homeostatic sleep regulation. Finally, a testable model is presented. The model proposes that in people with a vulnerability to develop insomnia, the locus coeruleus is more sensitive to-or receives more input from-the salience network and related circuits, even during rapid eye movement sleep, when it should normally be sound asleep. This vulnerability may ignite a downward spiral of insufficient overnight adaptation to distress, resulting in accumulating hyperarousal, which, in turn, impedes restful sleep and moreover increases the risk of other mental health adversity. Sensitized brain circuits are likely to be subjectively experienced as "sleeping with one eye open". The proposed model opens up the possibility for novel intervention studies and animal studies, thus accelerating the ignition of a neuroscience of insomnia, which is direly needed for better treatment.

The Cycle of Daily Stress and Sleep: Sleep Measurement Matters

BACKGROUND

Disturbed sleep can be a cause and a consequence of elevated stress. Yet intensive longitudinal studies have revealed that sleep assessed via diaries and actigraphy is inconsistently associated with daily stress.

PURPOSE

We expanded this research by examining daily associations between sleep and stress using a threefold approach to assess sleep: sleep diaries, actigraphy, and ambulatory single-channel electroencephalography (EEG).

METHODS

Participants were 80 adults (mean age = 32.65 years, 63% female) who completed 7 days of stressor and sleep assessments. Multilevel models were used to examine bidirectional associations between occurrence and severity of daily stress with diary-, actigraphy-, and EEG-determined sleep parameters (e.g., total sleep time [TST], sleep efficiency, and sleep onset latency, and wake after sleep onset [WASO]).

RESULTS

Participants reported at least one stressor 37% of days. Days with a stressor were associated with a 14.4-min reduction in actigraphy-determined TST (β = -0.24, p = 0.030), but not with other actigraphy, diary, or EEG sleep measures. Nights with greater sleep diary-determined WASO were associated with greater next-day stressor severity (β = 0.01, p = 0.026); no other diary, actigraphy, or EEG sleep measures were associated with next-day stressor occurrence or severity.

CONCLUSIONS

Daily stress and sleep disturbances occurred in a bidirectional fashion, though specific results varied by sleep measurement technique and sleep parameter. Together, our results highlight that the type of sleep measurement matters for examining associations with daily stress. We urge future researchers to treat sleep diaries, actigraphy, and EEG as complementary-not redundant-sleep measurement approaches.

Insomnia during COVID-19 pandemic and lockdown: Prevalence, severity, and associated risk factors in French population

In response to Voitsidis et al. (2020) published in Psychiatry Research addressing the paucity of research on insomnia during a pandemic, we obtained data from an online cross-sectional survey by documenting the prevalence of clinical insomnia and its contributing factors in a French general public sample. Participants (N = 556) completed the Insomnia Severity Index, UCLA Loneliness scale, and provided information on sociodemographics, antecedents of mental and physical health conditions, and COVID-19-related stressful life events. In our sample, 19.1% met the diagnostic criteria of clinical insomnia, which was twice lower than that reported in the study by Voitsidis et al., but close to those found among Chinese and Italian populations. We confirmed COVID-19-related worries and loneliness to be the major contributing factors to clinical insomnia, in addition to education status, being infected by the virus and pre-existing mental health illness. These findings underscore that sleep-related problems should be an important component of mental health interventions during pandemics.

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.

Nocturnal cognitive arousal is associated with objective sleep disturbance and indicators of physiologic hyperarousal in good sleepers and individuals with insomnia disorder

BACKGROUND

Cognitive arousal is central to models of sleep disturbance and insomnia, but findings remain mixed regarding whether cognitive arousal is associated with objective sleep disturbance and physiologic hyperarousal. This study explored associations of objective nocturnal wakefulness and indicators of physiologic hyperarousal with cognitive arousal in healthy sleepers and individuals with insomnia.

METHODS

In sum, 52 adults (51.9% women; 18 with insomnia disorder, 34 healthy sleepers) underwent two overnight polysomnography (PSG) studies (adaptation + baseline nights) and a multiple sleep latency test (MSLT). Baseline depression was assessed and presleep cognitive arousal and somatic arousal were recorded for each night. Multivariate regression was used to evaluate associations of PSG sleep parameters with insomnia, cognitive arousal, and somatic arousal.

RESULTS

Analyses showed that high levels of nocturnal cognitive arousal were associated with prolonged sleep latency, lower sleep efficiency, and shorter total sleep time by PSG on both nights. An association between nocturnal cognitive arousal and wake after sleep onset was observed on night one only. Moreover, greater nocturnal cognitive arousal was associated with greater likelihood of obtaining short sleep and with longer MSLT sleep latencies. Insomnia diagnosis, depression, and somatic arousal were not associated with PSG sleep parameters or MSLT latency.

CONCLUSIONS

Heightened cognitive arousal at night is linked to objective sleep disturbances and indicators of physiologic hyperarousal at night and during the day. For patients with insomnia, cognitive arousal may contribute to the 24-hr physiologic hyperarousal. Cognitive arousal may be a critical therapeutic target for severe or treatment-resistant sleep disturbance.

Changes in sleep pattern and sleep quality during COVID-19 lockdown

INTRODUCTION

To mitigate the spread of the pandemic coronavirus infection (COVID-19), governments across the world have adopted "lockdowns" which have confined many individuals to their homes. This disrupts normal life routines, elements of which are important circadian cues. The pandemic is also associated with new stressors, altered roles, and uncertainties about health and economic security, which are also likely to affect sleep. The current study is an online survey of sleep experience, routines, physical activity, and symptoms of anxiety and depression, to study the alterations associated with the lockdown.

MATERIALS AND METHODS

The survey was conducted in early May 2020 using a questionnaire circulated through social media platforms. Questions related to demographic characteristics, current and previous sleep schedules, routine, and working patterns. Insomnia (Insomnia Severity Index - 4), Stress (Perceived Stress Scale - 4), anxiety and depressive symptoms (Patient Health Questionnaire - 4) and physical activity (International Physical Activities Questionnaire) were assessed using standardized instruments.

RESULTS

A total of 958 valid responses were received. Compared to the prelockdown period, there was a shift to a later bedtime and waking time, with a reduction in night-time sleep and an increase in day-time napping. These effects were visible across occupational groups, but mostly affected working individuals except health professionals. Sleep quality deteriorated across groups. Reductions in sleep duration were associated with depressive symptoms.

CONCLUSIONS

The COVID-19 lockdown is associated with changes in sleep schedule and in the quantity and quality of night-time sleep. Although these changes are associated with elevated rates of emotional symptoms, it is unclear from these cross-sectional results, whether sleep deterioration produces psychological distress, or vice versa.

Work-Related Mental Fatigue, Physical Activity and Risk of Insomnia Symptoms: Longitudinal Data from the Norwegian HUNT Study

OBJECTIVE/BACKGROUND

To examine the prospective association between work-related mental fatigue and risk of insomnia symptoms, and if leisure time physical activity modifies this association.

PARTICIPANTS

A total of 8,464 women and 7,480 men who participated in two consecutive surveys of the Norwegian HUNT study.

METHODS

The study comprises longitudinal data on persons who were vocationally active and without insomnia symptoms at baseline in 1995-1997. We used a modified Poisson regression model to calculate adjusted risk ratios (RRs) with a 95% confidence interval (CI) for insomnia symptoms at follow-up in 2006-2008 associated with work-related mental fatigue and leisure time physical activity at baseline.

RESULTS

Women and men who always experienced mental fatigue after a workday had RRs of insomnia symptoms of 2.55 (95% CI 1.91-3.40) and 2.61 (95% CI 1.80-3.78), respectively, compared to workers who never or seldom had this experience. There was no strong modifying effect of leisure time physical activity on this association, but workers who always experienced mental fatigue had a RR of insomnia symptoms of 3.17 (95% CI 2.28-4.40) if they reported low physical activity and a RR of 2.52 (95% 1.89-3.39) if they reported high physical activity.

CONCLUSION

This study shows that work-related mental fatigue, caused by high cognitive workload, is a strong risk factor for insomnia symptoms. There was no clear modifying effect of leisure time physical activity but workers who experienced excessive work-related fatigue accompanied by low physical activity had the highest risk of insomnia symptoms.

Quantifying impact of real-world barriers to sleep: The Brief Index of Sleep Control (BRISC)

OBJECTIVE

Lack of control over sleep may contribute to population-level sleep disturbances, yet relatively little work has explored the degree to which an individual's sense of control over their sleep may represent an important factor.

METHODS

Data from the Sleep and Healthy Activity Diet Environment and Socialization (SHADES) study, conducted in the Philadelphia area on a population comprising 1,007 individuals aged 22-60 years, was used. The BRief Index of Sleep Control (BRISC) was developed to quantify the degree to which an individual has control over their sleep. Reliability of the BRISC was assessed using Cronbach's alpha. Convergent validity was assessed by examining age-adjusted items and total score relationships to insomnia (ISI), sleepiness (ESS), sleep quality (PSQI), and total sleep time (NHANES).

RESULTS

After adjustment for covariates, greater control over sleep was associated with a lower PSQI score (B = -2.2, 95% CI [-2.4,-2.0], P < .0001), lower ISI score (B = -3.1, 95% CI [-3.5,-2.7], P < .0001), lower ESS score (B=-1.4, 95% CI [-1.7,-1.1], P < .0001), and more hours of sleep duration (B = 0.5, 95% CI [0.4,0.6], P < .0001). Each BRISC item was separately associated with each sleep outcome (P < .0001), although the items were not collinear with each other (all R<0.7). Thus, the BRISC instrument demonstrated high reliability and good validity.

CONCLUSIONS

Control over sleep may represent an important factor in sleep health. Control over time to bed, time awake, sleep duration, and sleep quality are all related to sleep outcomes and assessment of these constructs may be useful for future sleep interventions.

Cognitive behavioural therapy for insomnia in patients with rheumatoid arthritis: protocol for the randomised, single-blinded, parallel-group Sleep-RA trial

BACKGROUND

More than half of patients with rheumatoid arthritis complain of insomnia, which is predominantly treated with hypnotic drugs. However, cognitive behavioural therapy for insomnia is recommended as the first-line treatment in international guidelines on sleep. Patients with rheumatoid arthritis suffer from debilitating symptoms, such as fatigue and pain, which can also be linked to sleep disturbance. It remains to be determined whether cognitive behavioural therapy for insomnia can be effective in patients with rheumatoid arthritis. The aim of the Sleep-RA trial is to investigate the efficacy of cognitive behavioural therapy for insomnia on sleep and disease-related symptoms in patients with rheumatoid arthritis. The primary objective is to compare the effect of cognitive behavioural therapy for insomnia relative to usual care on changes in sleep efficiency from baseline to week 7 in patients with rheumatoid arthritis. The key secondary objectives are to compare the effect of cognitive behavioural therapy for insomnia relative to usual care on changes in sleep onset latency, wake after sleep onset, total sleep time, insomnia, sleep quality, fatigue, impact of rheumatoid arthritis and depressive symptoms from baseline to week 26 in patients with rheumatoid arthritis.

METHODS

The Sleep-RA trial is a randomised controlled trial with a two-group parallel design. Sixty patients with rheumatoid arthritis, insomnia and low-to-moderate disease activity will be allocated 1:1 to treatment with cognitive behavioural therapy for insomnia or usual care. Patients in the intervention group will receive nurse-led, group-based cognitive behavioural therapy for insomnia once a week for 6 weeks. Outcome assessments will be carried out at baseline, after treatment (week 7) and at follow-up (week 26).

DISCUSSION

Data on treatment of insomnia in patients with rheumatoid arthritis are sparse. The Sleep-RA trial is the first randomised controlled trial to investigate the efficacy of cognitive behavioural therapy for insomnia in patients with rheumatoid arthritis. Because symptoms of rheumatoid arthritis and insomnia have many similarities, we also find it relevant to investigate the secondary effects of cognitive behavioural therapy for insomnia on fatigue, impact of rheumatoid arthritis, depressive symptoms, pain, functional status, health-related quality of life and disease activity. If we find cognitive behavioural therapy for insomnia to be effective in patients with rheumatoid arthritis this will add weight to the argument that evidence-based non-pharmacological treatment for insomnia in rheumatological outpatient clinics is eligible in accordance with the existing international guidelines on sleep.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03766100. Registered on 30 November 2018.

Objective Measures of Sleep Apnea and Actigraphy-Based Sleep Characteristics as Correlates of Subjective Sleep Quality in an Epidemiologic Study: The Jackson Heart Sleep Study

OBJECTIVE

Self-reported "sleep quality" often is assessed in epidemiologic studies. However, the bases for variation in sleep quality is not fully understood. We quantified the extent to which subjective sleep quality was related to sleep disorders and sleep characteristics among 795 African American adults.

METHOD

Between 2012 and 2016, participants underwent home sleep apnea testing and 1-week actigraphy (estimating sleep duration, efficiency, fragmentation, latency). Sleep quality, insomnia and restless legs syndrome symptoms, sleepiness, and physician diagnosis of sleep disorders were self-reported. We fit linear regression models to determine the extent to which subjective and objective sleep measures as well as depressive symptoms and anxiety were related to subjective sleep quality.

RESULTS

After adjustment for covariates, worse sleep quality scores were associated with insomnia and restless legs syndrome symptoms, sleep apnea, physician diagnosis of a sleep disorder, and actigraphy-based fragmented sleep, lower sleep efficiency, and shorter sleep duration. Insomnia symptoms explained the most variance in subjective sleep quality, 21%. Other sleep measures each explained 3% to 7% and psychosocial factors explained 8% to 9% of the variance in subjective sleep quality after adjustment for confounders.

CONCLUSIONS

The weak associations of sleep quality with sleep disorders and objectively measured sleep disturbances are consistent with concepts of "sleep health" as a multidimensional construct. Sleep quality is a patient-centered outcome that provides unique information over objective measurements of sleep disturbances.

Light-enhanced cognitive behavioural therapy for sleep and fatigue: study protocol for a randomised controlled trial during chemotherapy for breast cancer

BACKGROUND

Women with breast cancer experience a significantly higher prevalence of sleep disturbance and insomnia than the general population. The experience of persistent sleep disturbance places these women at a higher risk of psychological and physical morbidity and a reduced quality of life. Treatment for sleep in this population is not part of routine care and is often managed inadequately. This randomised controlled trial will examine the combined effects of cognitive behavioural therapy (CBT) and bright light therapy (BLT) on the symptoms of insomnia, fatigue and mental health.

METHOD/DESIGN

Women diagnosed with breast cancer who receive intravenous chemotherapy treatment at a quaternary referral metropolitan cancer centre in Melbourne, Australia, will be recruited. Recruitment will occur after diagnosis and prior to completion of chemotherapy. Eligible women will be randomised to the combined CBT and BLT intervention (CBT+) or relaxation audio-enhanced treatment as usual (TAU+). The CBT+ group will receive one face-to-face session on sleep strategies, one subsequent telephone call, and seven email packages containing CBT-based information and strategies. CBT+ participants will also wear Luminette® light glasses for 20 min each morning for the 6-week duration of the intervention. Women in TAU+ will receive two relaxation audio tracks via email. Outcomes will be measured at multiple points throughout the 6 weeks. Primary outcomes will be symptoms of insomnia and sleep efficiency, measured using the Insomnia Severity Index and a self-reported sleep diary. Secondary outcomes include objective measures of sleep assessed using the ActiGraph wGT3X-BT, and sleep-related complaints, fatigue and mental health, all assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS). Data will also be collected on potential treatment moderators and mechanisms and adherence to treatment. There will be 3-month follow-up measurements of insomnia symptoms, fatigue, sleep-related impairment, sleep disturbance, depression and anxiety.

DISCUSSION

This is the first randomised controlled trial to combine CBT and BLT for the treatment of sleep disturbance in women with breast cancer. This novel design addresses the multiple causal factors for sleep complaints in this population. Results from this trial will advance knowledge in this field and may have important clinical implications for how best to treat sleep disturbance and insomnia in this population. If effective, the largely email-based format of the intervention would allow for relatively easy translation.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12618001255279. Retrospectively registered on 25 July 2018.

Measurement invariance, validation and normative data of the Jenkins Sleep Scale-4 (JSS-4) in the German general population across the life span

OBJECTIVE

As sleep disorders have become a major concern in public health, there is strong need for a brief and sound measure for sleep problems. The purposes of the study were to 1) evaluate factor structure and measurement invariance, 2) validate the scale based on sociodemographic data and distress, and 3) provide norm values for the general population.

METHODS

In a representative survey of the German population N = 2515 participants (14 to 95 years) filled in the 4-item Jenkins Sleep Scale (JSS-4), sociodemographic questions and the Brief Symptom Inventory-18 (anxiety, depression, somatic symptom load). The JSS-4 was analyzed by principal component analysis, confirmatory and multi-group confirmatory factor analyses. A multiple-indicator-multiple-cause model was tested to investigate the relationship of the JSS-4 to distress and sociodemographic variables.

RESULTS

The one-factor structure of JSS-4 was confirmed. Given the heterogeneity of facets of sleep problems captured in the four items, internal consistency of the JSS-4 was remarkably high. The JSS-4 was strictly invariant across both sexes, and partially strictly invariant across income groups and individuals living with or without a partner. With regard to the full age range, it showed partial scalar invariance.

CONCLUSION

Female sex, higher age, living without a partner, lower education, lower income and increased distress were associated with more sleep problems. Calculated normative data of sleep problems allow comparisons of JSS-4 scores stratified by sex and age.

Hyperarousal Scale: Italian Cultural Validation, Age and Gender Differences in a Nonclinical Population

Objectives. Studies on hyperarousal have increasingly developed in the last decade. Nevertheless, there are still very few valid measures of hyperarousal. The aim of the study is to verify the psychometric properties of the Italian version of the Hyperarousal Scale (H-Scale), in order to provide researchers with a valid measure for the target population. Method. The questionnaire was translated, back-translated, pre-tested, and cross-culturally adapted. Subsequently, the Italian version of the H-Scale, the Anxiety Sensitivity Index (ASI-3) and the Health Survey Questionnaire (SF-36) were administered to 982 adults, 456 males and 526 females, aged from 18 to 80 years (M = 35.61 ± 12.47). Results. Cronbach’s alpha of the translated H-Scale was 0.81. Furthermore, positive correlations with the ASI-3 and negative correlations with the SF-36 emerged. The H-Scale is also sensitive to catch age and gender differences. Conclusions. The Italian version of the H-Scale demonstrated good reliability and validity. Its sufficient discriminative and evaluative psychometric properties provide the theoretical evidence for further application in evidence-based research studies.

Cardiorespiratory fitness, sleep, and physiological responses to stress in women

Epidemiological studies suggest that cardiorespiratory fitness (CRfitness) is associated with reduced risk of depression and anxiety in women, however, the mechanisms by which CRfitness may be protective against the development of these disorders are less clear. Because sleep problems are associated with both a higher risk for mental illness and altered physiological responses to stress, this study investigated whether sleep quality might influence the relationship between CRfitness and physiological stress responses in women. Thirty healthy women (18-45 y) who were medication-free, with regular menstrual cycles completed: (1) enrolment visit [including the assessment of CRfitness via maximal oxygen consumption during exercise]; (2) one-week sleep monitoring period including subjective (daily sleep diaries) and objective (wrist actigraphy) sleep measures; and (3) psychosocial stressor protocol (the Trier Social Stress Test; TSST) for the collection of heart rate (HR), blood pressure (BP), and salivary cortisol stress responses. Higher CRfitness was associated with reduced wake after sleep onset (WASO) duration (r = -.38, p = 0.04), higher self-reported sleep quality (higher scores reflect poorer sleep quality; r = -.37, p = 0.05), and lower HR (r = -.43, p = 0.02) during the stressor. Higher sleep quality was associated with a lower HR during the stressor (r = .44, p = 0.01). Increased WASO duration and WASO number were associated with blunted cortisol output during the stressor (r = -.44, p = 0.02, and r = -.46, p = 0.02, respectively). Results suggest that, in women, CRfitness may be protective against the deleterious effects of stress via improved sleep quality.

The Evaluation of Autonomic Arousals in Scoring Sleep Respiratory Disturbances with Polysomnography and Portable Monitor Devices: A Proof of Concept Study

BACKGROUND

Autonomic arousals can be considered as surrogates of electroencephalography (EEG) arousals when calculating respiratory disturbance index (RDI). The main objective of this proof of concept study was to evaluate the use of heart rate acceleration (HRa) arousals associated with sleep respiratory events in a population undergoing full polysomnography (type 1) and in another undergoing portable monitor study (type 3). Our hypothesis is that when compared to other commonly used indexes, RDI based on HRa will capture more events in both types of recording.

MATERIALS AND METHODS

A retrospective analysis was performed in two different populations of patients with suspected OSA: a) 72 patients undergoing one night of type 1 recording and b) 79 patients undergoing one night of type 3 recording. Variables for type 1 were 4% oxygen desaturation index (ODI), apnea/hypopnea index (AHI), RDI based on EEG arousals (RDIe), and RDI based on HRa with threshold of 5bpm (RDIa5). For type 3, variables were 4% ODI, AHI, and RDIa5 (it is not possible to calculate RDIe due to the absence of EEG). Calculated data were 1) Mean values for each sleep disturbance index in type 1 and 3 recordings; 2) Frequency of migration from lower to higher OSA severity categories using RDIa5 in comparison to AHI (thresholds: ≥5/h mild, ≥15/h moderate, ≥30/h severe); and 3) Bland-Altman plots to assess agreement between AHI vs RDIe and RDIa5 in type 1 population, and AHI vs RDIa5 in type 3 populations.

RESULTS

More respiratory disturbance events were captured with RDIa5 index in both type 1 and type 3 recordings when compared to the other indexes. In type 1 recording, when using RDIa5 37% of patients classified as not having OSA with AHI were now identified as having OSA, and a total of 59% migrated to higher severity categories. In type 3 recording, similar results were obtained, as 37% of patients classified as not having OSA with AHI were now identified as having OSA using RDIa5, and a total of 55% patients migrated to higher severity categories. Mean differences for RDIa5 and AHI in type 1 and 3 populations were similar.

CONCLUSION

The use of autonomic arousals such as HRa can help to detect more respiratory disturbance events when compared to other indexes, being a variable that may help to capture borderline mild cases. This becomes especially relevant in type 3 recordings. Future research is needed to determine its validity, optimization, and its clinical significance.

Effects of Brief Behavioral Treatment for Insomnia on Daily Associations between Self-Reported Sleep and Objective Cognitive Performance in Older Adults

OBJECTIVE

Behavioral treatments for insomnia improve sleep in older adults, but research documenting their effects on cognitive performance is mixed. We explored whether a brief behavioral treatment for insomnia (BBTi) impacts daily associations between sleep parameters and next day cognition.

METHODS

Sixty-two older adults (M_age = 69.45 years, SD = 7.71) with insomnia completed either 4 weeks of BBTi or self-monitoring control (SMC). At baseline, post-treatment, and 3 month follow-up, participants completed 14 days of diaries measuring sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency (SE), as well as daily cognitive tests measuring processing speed (i.e., symbol digit modalities test, SDMT), and reasoning (i.e., letter series). At each time period, associations between sleep parameters and daily cognition, controlling for age, education, insomnia duration, use of sleep medications, and depression (i.e., Beck Depression Inventory-2^nd Edition scores), were examined through multilevel modeling.

RESULTS

At post-treatment, we observed an interactive fixed effect of treatment condition (i.e., BBTi/SMC) and TST on daily SDMT and letter series performance. For BBTi, longer TST was associated with better letter series performance, and did not predict SDMT performance. For SMC, longer TST was associated with worse SDMT, and was not associated with letter series performance. Greater WASO (regardless of group) was associated with better SDMT performance at post-treatment. Associations were not maintained at follow-up.

CONCLUSIONS

Sleep duration may play an important role in BBTi-related improvements in daily higher order cognition. Maintenance of these associations may be facilitated by booster sessions following post-treatment.

CLINICAL TRIAL IDENTIFIER

NCT02967185.

Intraindividual variability in sleep and perceived stress in young adults

OBJECTIVES

Research suggests strong associations between habitual sleep parameters (eg, mean duration, timing, efficiency), perceived stress, and insomnia symptoms. The associations between intraindividual variability (IIV; night-to-night within-person variation) in sleep, perceived stress, and insomnia have not been explored. This study examined associations between IIV in subjectively and objectively determined sleep parameters and to perceived stress in young adults with and without insomnia.

DESIGN

Prospective longitudinal.

SETTING AND PARTICIPANTS

Participants were 149 college students (mean age = 20.2 [SD = 2.4], 59% female) either with insomnia (n = 81; 54%) or without insomnia (n = 68; 46%).

MEASUREMENTS

Participants completed 1 week of daily sleep diaries and actigraphy (to assess total sleep time [TST], sleep efficiency [SE], and circadian midpoint [CM]), the Perceived Stress Scale, and a diagnostic interview for determination of insomnia as part of a parent study.

RESULTS

Greater IIV in actigraphy-determined TST (but not SE or CM) was independently associated with greater perceived stress, regardless of insomnia status. Greater IIV in sleep diary-determined TST, SE, or CM was not associated with perceived stress. Insomnia status was the most robust predictor of elevated perceived stress. There was a significant interaction between IIV in sleep diary-determined TST and insomnia status on perceived stress: Only in those without insomnia was greater IIV in sleep diary-determined TST associated with higher perceived stress.

CONCLUSION

Maintaining a more consistent sleep duration may be associated with lower stress in college students. Future research is needed to clarify the directionality and implications of this association for treatment.

Sleep Problems and Workplace Violence: A Systematic Review and Meta-Analysis

Background: This systematic review with meta-analysis was carried out to study the relationship between workplace violence and sleep problems.

Methods: The PRISMA statement was used to conduct a systematic search of the literature on PubMed/MEDLINE, Scopus, Sociological abstract, DOAJ, Web of Science, and Google Scholar databases. Of the original number of 749 studies, 34 were included in the systematic review, and 7 in the meta-analysis.

Results: A total of 119,361 participants from 15 different countries took part in these studies which were published between 1999 and 2019. Significant heterogeneity was observed among the studies (I² = 96%). In a random-effects meta-analysis model, pooled odds ratio (OR) analysis revealed that there was a direct relationship between occupational exposure to violence and sleep problems (OR = 2.55; 95% CI = 1.77–3.66). According to the GRADE guidelines, the quality of evidence of the association was low.

Conclusions: The findings of this study demonstrate that occupational exposure to physical, verbal, or sexual violence is associated with sleep problems. Further research on the relationship between violence and sleep is needed so that appropriate measures can be taken to prevent violence and improve sleep hygiene in the workplace.

Trial Registration Number: PROSPERO International prospective register of systematic reviews (CRD42019124903) February 9, 2019.

Sexual function and distress in postmenopausal women with chronic insomnia: exploring the role of stress dysregulation

OBJECTIVE

Menopause triggers changes in sexual function and many women develop sexual problems. Insomnia is common in postmenopausal women, and disturbed sleep has been linked to poor sexual health. Thus, postmenopausal women with insomnia may be especially vulnerable to developing sexual difficulties. This study estimated rates of sexual distress in postmenopausal women with chronic insomnia and explored associations between various facets of sexual health, insomnia symptoms, and insomnia-related stress dysregulation.

DESIGN

Cross-sectional.

SETTING

Large multi-site health system in the US.

PARTICIPANTS

150 postmenopausal women diagnosed with DSM-5 chronic insomnia disorder (56.44±5.64 years) completed measures of sexual distress, sexual function, hot flashes, insomnia symptoms, depression, and stress dysregulation in the forms of cognitive-emotional arousal (worry, rumination), sleep reactivity, and somatic hyperarousal.

RESULTS

Nearly half of the sample endorsed clinically significant sexual distress (46.9%). Insomnia symptoms were largely associated with poor sexual arousal, orgasmic dysfunction, sexual distress, and sexual dissatisfaction. Insomnia-related stress dysregulation was similarly associated with these facets of sexual health but was also linked to problems with low desire and greater vaginal pain during sex. Hot flashes and depression were negatively associated with sexual health.

CONCLUSION

Postmenopausal women with chronic insomnia endorse high rates of sexual distress. Although compromised sexual function appears directly related to poor sleep itself, our data suggest that stress dysregulation may play vital role in sexual problems endorsed by postmenopausal insomniacs, particularly regarding low desire and vaginal pain. Prospective research is needed to characterize the evolution of these co-occurring symptoms.

British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update

This British Association for Psychopharmacology guideline replaces the original version published in 2010, and contains updated information and recommendations. A consensus meeting was held in London in October 2017 attended by recognised experts and advocates in the field. They were asked to provide a review of the literature and identification of the standard of evidence in their area, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. Each presentation was followed by discussion, aiming to reach consensus where the evidence and/or clinical experience was considered adequate, or otherwise to flag the area as a direction for future research. A draft of the proceedings was circulated to all speakers for comments, which were incorporated into the final statement.

Over-indebtedness and its association with sleep and sleep medication use

BACKGROUND

Over-indebtedness is currently rising in high-income countries. Millions of citizens are confronted with the persistent situation when household income and assets are insufficient to cover payment obligations and living expenses. Previous research shows that over-indebtedness increases the risk of various adverse health effects. However, its association with sleep problems has not yet been examined. The objective of this study was to investigate the association between over-indebtedness and sleep problems and sleep medication use.

METHODS

A cross-sectional study on over-indebtedness (OID survey) was conducted in 70 debt advisory centres in Germany in 2017 that included 699 over-indebted respondents. The survey data were combined with the nationally representative German Health Interview and Examination Survey for Adults (DEGS1; n = 7987). We limited analyses to participants with complete data on all sleep variables (OID: n = 538, DEGS1: n = 7447). Descriptive analyses and logistic regression analyses were used to examine the association between over-indebtedness and difficulty initiating and maintaining sleep, and sleep medication use.

RESULTS

A higher prevalence of sleep problems and sleep medication use was observed among over-indebted individuals compared to the general population. After adjustment for socio-economic and health factors (age, sex, education, marital status, employment status, subjective health status and mental illness), over-indebtedness significantly increased the risk of difficulties with sleep onset (adjusted odds ratio (aOR) 1.79, 95%-confidence interval (CI) 1.45-2.21), sleep maintenance (aOR 1.45, 95%-CI 1.17-1.80) and sleep medication use (aOR 3.94, 95%-CI 2.96-5.24).

CONCLUSIONS

Evidence suggests a strong association between over-indebtedness and poor sleep and sleep medication use independent of conventional socioeconomic measures. Considering over-indebtedness in both research and health care practice will help to advance the understanding of sleep disparities, and facilitate interventions for those at risk.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00013100 (OID survey, ArSemü); Date of registration: 23.10.2017; Date of enrolment of the first participant: 18.07.2017, retrospectively registered.

The relationship between sleep quality and all-cause, CVD and cancer mortality: the Southall and Brent REvisited study (SABRE)

BACKGROUND

Both long and short sleep duration increase risk of mortality. Most previous studies have been performed in Europeans and have focused on sleep duration. Thus, we aimed to investigate the association between sleep quality and mortality across three different ethnic groups.

METHODS

We used data from the Southall and Brent REvisited Study (SABRE) cohort, which comprises first generation migrant South Asian and African Caribbean men and women, aged 40-69 years, recruited between 1988 and 1991. In sum, 4399 participants provided complete data at baseline and follow-up. Of those, 1656 died by December 2017. Our exposures (eg, difficulty falling asleep, early morning waking and waking up tired in the morning) were self-reported and our primary outcome was mortality. We used Cox proportional hazards models to analyse our data, adjusting for baseline-measured confounders.

RESULTS

None of the sleep measures were strongly associated with all-cause mortality in Europeans or African Caribbeans, whilst in South Asians difficulty falling asleep was related to an increased risk of all-cause mortality (HR = 1.28, 95%CI = 1.01; 1.61). In Europeans, early morning waking was associated with a moderately increased risk of cardiovascular death (HR = 1.31, 95%CI = 1.05; 1.63); alternately, this association was not as strong in the other groups.

CONCLUSION

Our findings suggest that the relationship between sleep quality and mortality may differ by ethnic group, but formal heterogeneity tests indicated that the strongest difference in HRs was observed for early morning waking and cardiovascular disease (CVD) mortality across the three groups (Cochran's Q test p = 0.036). As such, these results are novel and provide support for ethnic differences in sleep quality and mortality, and may have implications for precision medicine.

Treating insomnia improves depression, maladaptive thinking, and hyperarousal in postmenopausal women: comparing cognitive-behavioral therapy for insomnia (CBTI), sleep restriction therapy, and sleep hygiene education

INTRODUCTION

Depression increases during menopause, and subclinical depressive symptoms increase risk for major depression. Insomnia is common among postmenopausal women and increases depression-risk in this already-vulnerable population. Recent evidence supports the efficacy of cognitive-behavioral therapy for insomnia (CBTI) to treat menopausal insomnia, but it remains unclear whether treating insomnia also alleviates co-occurring depressive symptoms and depressogenic features. This trial tested whether CBTI improves depressive symptoms, maladaptive thinking, and somatic hyperarousal in postmenopausal women with insomnia; as well as whether sleep restriction therapy (SRT)-a single component of CBTI-is equally efficacious.

MATERIALS AND METHODS

Single-site, randomized controlled trial. 117 postmenopausal women (56.34 ± 5.41 years) with peri-or-postmenopausal onset of chronic insomnia were randomized to three treatment conditions: sleep hygiene education control (SHE), SRT, and CBTI. Blinded assessments were performed at baseline, posttreatment, and six-month follow-up.

RESULTS

CBTI produced moderate-to-large reductions in depressive symptoms, whereas SRT produced moderate reductions but not until six months posttreatment. Treatment effects on maladaptive thinking were mixed. CBTI and SRT both produced large improvements in dysfunctional beliefs about sleep, but weaker influences on presleep cognitive arousal, rumination, and worry. Presleep somatic arousal greatly improved in the CBTI group and moderately improved in the SRT group. Improvements in depression, maladaptive thinking, and hyperarousal were linked to improved sleep. SHE produced no durable treatment effects.

CONCLUSIONS

CBTI and SRT reduce depressive symptoms, dysfunctional beliefs about sleep, and presleep somatic hyperarousal in postmenopausal women, with CBTI producing superior results. Despite its cognitive emphasis, cognitive arousal did not respond strongly or durably to CBTI. NAME: Behavioral Treatment of Menopausal Insomnia: Sleep and Daytime Outcomes. URL: clinicaltrials.gov.

REGISTRATION

NCT01933295.

Altered Default Mode and Sensorimotor Network Connectivity With Striatal Subregions in Primary Insomnia: A Resting-State Multi-Band fMRI Study

Background: Primary insomnia is a high prevalent sleep disorder. Disturbed brain activity during reward, emotional, and cognitive processing have been observed in insomnia patients. Studies have implicated a critical role of the striatum in these dysfunctions. However, there have been no direct investigations on the whole-brain functional connectivity (FC) of the striatum in insomnia.

Methods: We analyzed the group differences in the FC images of 6 predefined striatal subregions based on the multi-band resting-state fMRI data of 18 insomnia patients and 16 healthy controls.

Results: We found increased positive FC in the bilateral medial frontal gyrus for bilateral dorsal caudate (DC) and left inferior ventral striatum (VS) subregions, but increased negative FC in the bilateral inferior parietal lobe for the left inferior VSi and right dorsal caudal putamen (DCP) subregions, and in the lateral temporal, occipital, and primary sensorimotor areas for the bilateral DC and left superior VS subregions. The FC between the right DCP and right inferior parietal lobe showed significant positive correlation with Pittsburgh Sleep Quality Index (PSQI).

Conclusion: The findings indicate disturbed striatal FC with the default mode network (DMN), the visual and somatosensory areas in insomnia, which likely reflects an inappropriate reward or emotional significance attribute to self-reflection, episodic memory, sensory-perception processes. The altered striatal FC might increase the risk of insomnia patients to develop depression and anxiety.

[Evidence-Based Treatment of Insomnia]

Evidence-Based Treatment of Insomnia Abstract. This review article presents current evidence on the diagnosis and efficacy of treatment methods for non-organic insomnia. In diagnostics, it is particularly important to examine differential diagnoses individually and, if available, to treat them. Regarding the actual insomnia treatment, it should be emphasized that drug treatment provides proof of efficacy only in short-term treatments lasting less than four weeks. The most effective treatment for insomnia is disorder-specific cognitive-behavioral psychotherapy (CBT-I). CBT-I should therefore be accessible to every patient with insomnia.