0120 Association Between Sleep Duration and Daytime Memory and Cognition Depends on Sleep Quality: Data from the 2017 Israel Social Survey

Introduction

This study examines the relationship between sleep duration, sleep disturbance, and cognitive problems in a representative sample of the Israeli population.

Methods

7,230 Israelis responded to an Israeli Bureau of Statistics population-based survey of households from the year 2017. All variables were self-reported. Outcome of interest was difficulty with memory/concentration (none, mild, or severe). Predictors included previous month sleep duration (<=5hrs, 6hrs, 7hrs [reference], 8hrs, or >=9hrs) and sleep disturbance (none [reference], mild [1/week], moderate [2–3/week], or severe [>3/week]). Covariates included age, sex, ethnic group, and financial status. Multinomial logistic regressions evaluated the relationships between variables, and post-hoc testing identified relationships within specific subgroups.

Results

72.9% denied cognitive problems, 22.2% reported mild problems, and 4.9% severe problems. In adjusted analyses, Sleep <=5hrs and >=9hrs were associated with mild (RRR=1.39, p<0.0005), (RRR=1.46, p=0.004) and severe (RRR=2.75, p<0.0005), (RRR=3.24, p<0.0005) cognitive problems, respectively. Mild, moderate, and severe sleep difficulties were associated with mild cognitive problems (RRR=2.09, p<0.0005), (RRR=2.22, p<0.0005), (RRR=2.44, p<0.0005), and severe cognitive problems (RRR=1.77, p=0.001), (RRR=3.04, p<0.0005), (RRR=4.22, p<0.0005), respectively. There was an interaction between sleep duration and sleep difficulties (p<0.05). Among those denying sleep difficulties, only >=9hrs of sleep was associated with cognitive problems. Among those with mild, moderate, and severe sleep difficulties, both short and long sleep were associated with cognitive problems.

Conclusion

In an Israeli population sample, both sleep duration and quality were associated with cognitive problems. Among those with sleep difficulties, short and long sleep duration were associated with cognitive problems, but among those denying sleep difficulties, only long sleep was associated with cognitive problems. These results suggest that the impact of sleep loss on real-world cognition may also rely on the presence of poor sleep quality.

Support

Dr. Grandner is supported by R01MD011600

1096 Morning Wakefulness is Associated with Reduced Suicidal Ideation in a Nationally-Representative US Sample

Introduction

Nocturnal wakefulness is a unique risk factor for suicidal ideation in clinical as well as community samples. Preliminary data suggest that morning wakefulness may also be a protective factor against such thinking. However, these associations have not been explored in a nationally-representative dataset.

Methods

Data were collected from the 2015-2016 wave of the National Health and Nutrition Examination Survey. Participants reported typical bedtimes and waketimes. From these values, wakefulness during the night (00:00 to 05:59), morning (06:00 to 11:59), afternoon (12:00 to 17:59), and evening (18:00 to 23:59) was determined. Suicidal ideation was assessed by a question about “thoughts that you would be better off dead, or thoughts of hurting yourself in some way.” Ordinal logistic regression estimated the association between the number of hours awake at particular times of day and the frequency of suicidal ideation. Additional analyses adjusted for demographic factors and depressed mood.

Results

Out of 5133 respondents with available data, 125 reported suicidal ideation several days a week, 36 reported suicidal ideation more than half the days, and 29 reported suicidal ideation nearly every day. When controlling for demographics, morning wakefulness was associated with reduced frequency of suicidal ideation (OR: 0.69, 95% CI: [0.59,0.8]). Controlling for depressed mood attenuated, but did not eliminate, this association. Nocturnal wakefulness was not associated with suicidal ideation in this sample.

Conclusion

Using data from a nationally representative sample, morning wakefulness was associated with less frequent suicidal ideation. However, previous findings regarding nocturnal wakefulness were not replicated. The limited number of individuals in the sample endorsing both suicidal ideation and nighttime wakefulness may have insufficient power to detect an association.

Support

Dr. Grandner is supported by R01MD011600.

0152 Insomnia Severity and Daytime Complaints: What is to be Learned When These Domains are Discordant?

Introduction

If illness severity and daytime dysfunction are construed as categorical entities, it is possible to conceptualize the relationship between these variables in terms of a 2x2 matrix where the resultant cells represent a concordant dimension (quadrants 2 & 4 [high-high and low-low]) and a discordant dimension (quadrants 1 & 3 [high-low and low-high]). The question for the present analysis was, what percentage of subjects populate each quadrant and is it the case that the discordant dimension contains only a small percentage of subjects?

Methods

Illness severity and daytime dysfunction data was collected from individuals with sleep continuity complaints in archival/community-based sample (N = 4680; 60% female; Ages 18–89) (www.sleeplessinphilly.com). Illness severity was operationalized as Total Wake Time (TWT; [SL+WASO+EMA=TWT]) and daytime dysfunction was operationalized as the composite score of six daytime symptoms items. Median splits were calculated for each variable and subjects were typed accordingly (HH, LL, HL, & LH).

Results

Surprisingly, the sample was relatively equally distributed into the two dimensions; 38% and 23% for the concordant dimension and 13% and 26% for discordant dimension.

Conclusion

The 39% of subjects in the discordant groups might be thought of as complaining good sleepers (LH) and noncomplaining poor sleepers (HL). Other investigators have identified the LH subjects as individuals with “insomnia identity”. Alternatively, it is possible to characterize the whole dimension as being related to a mismatch between the individual’s sleep need and sleep ability. Those who need a lot, may suffer a lot, in the face of only a little (LH) whereas those who need a little, may suffer only a little, in the face of a lot (HL).

Support

 

1108 Associations Between Insomnia And Anxiety Symptoms: Which Elements Of Insomnia Are Associated With Which Elements Of Anxiety?

Introduction

It is still not clear which aspects of insomnia are associated with various aspects of anxiety problems. Knowing this could better guide treatment of insomnia comorbid with anxiety.

Methods

Data from the Sleep and Healthy Activity, Diet, Environment, and Socialization (SHADES) study were used, including N=1003 adults age 22-60. All participants completed the Insomnia Severity Index (ISI) and the GAD7 anxiety questionnaire. The ISI was divided into 3 sections, based on prior work: SLEEP symptoms (difficulty sleeping), DAYTIME symptoms (difficulty functioning), and PERCEPTION symptoms (dissatisfaction). GAD7 items included anxiety level, loss of control, worry about many things, difficulty relaxing, restlessness, irritability, and fear. Logistic regression analyses examined each symptom, with each component of the ISI as predictor, as well as age, sex, race/ethnicity and education as covariates.

Results

SLEEP symptoms were independently associated with control (OR=1.09, p=0.03), many worries (OR=1.1, p=0.017), restlessness (OR=1.1, p=0.009), and irritability (OR=1.1, p=0.04). DAYTIME symptoms were independently associated with anxiety level (OR=1.3, p<0.0005), control (OR=1.2, p<0.0005), many worries (OR=1.3, p<0.0005), difficulty relaxing (OR=1.2, p=0.004), restlessness (OR=1.3, p=0.001), and irritability (OR=1.2, p<0.0005). PERCEPTION symptoms were uniquely, independently associated with anxiety level (OR=1.1, p=0.03), control (OR=1.2, p=0.001), many worries (OR=1.2, p=0.001), difficulty relaxing (OR=1.4, p<0.0005), irritability (OR=1.2, p=0.018), and feelings of fear (OR=1.2, p=0.002).

Conclusion

The DAYTIME and PERCEPTION symptoms of insomnia were strongly related to anxiety symptoms. Current treatments for insomnia focus mainly on improving sleep. Future research should test the hypothesis that treating daytime symptoms of insomnia may aid patients with comorbid anxiety.

Support

The SHADES study was funded by R21ES022931. Dr. Grandner is supported by R01MD011600.

0404 Jewish-Arab Disparities in Sleep Behaviors and Differential Ethnic Impact on Daytime Functioning, Driving Safety, and Health in Israel

Introduction

In Israel, those with Arabic as compared to Jewish ethnicity, exhibit poorer health and motor vehicle safety behaviors. Their ethnic differences in sleep duration and quality may modulate their vulnerabilities to these behaviors.

Methods

7,230 Israeli individuals (N=5,880 Jewish and N=1350 Arabic) responded to the 2017 Israeli Bureau of Statistics population-based survey of households. Variables were self-reported. Outcomes included sleepiness, sleep medications, functional impairment, drowsy driving, overall health, 1-year health change, and obesity. Predictors included categorical sleep duration (<=5, 6, 7, 8 [reference], or >=9 hours) and sleep disturbance in the past month (none [reference], mild [1/week], moderate [2-3/week], or severe [>3/week]). Covariates included age, sex, and financial status. Ethnicity (Jewish/Arabic) was treated as a predictor of sleep and behavioral outcomes.

Results

When compared to normal (8-hour) sleepers, Jewish as compared to Arabic individuals were more likely to to sleep <=5h (RRR=3.99, p<0.0005), 6h (RRR=4.65, p<0.0005), and 7h (RRR=3.34, p<0.0005), and were more likely to report severe sleep difficulties (RRR=1.49, p<0.0005) and sleepiness (oOR=1.52, p< 0.0005). Yet, they were less likely to report functional impairment (oOR=0.65, p<0.0005), drowsy driving (OR=0.58, p<0.0005), worse health (oOR=0.51, p<0005), worsening health (oOR=0.70, p<0.0005), or obesity (OR=0.64, p<0.0005). Significant ethnicity by sleep duration interactions (p<0.05) characterized sleepiness, sleep medications, functional impairment, health, and health change. Moreover, significant ethnicity by sleep disturbance interactions (p<0.05) characterized the same outcomes, in addition to drowsy driving. Overall, the impact of sleep duration and sleep difficulties was generally greater among Arabs for all variables.

Conclusion

Despite Jewish individuals endorsing relatively shorter sleep and more severe sleep difficulties, Arabs seem to be more vulnerable to the health and functional outcomes. This finding may explain some of the discrepancies in the health and safety outcomes between these ethnic groups.

Support

Dr. Grandner is supported by R01MD011600

1175 Sleep Disorders Screening in Primary Care: Prevalence of Diagnosis and Treatment in the EMR

Introduction

Undetected and untreated sleep disorders likely precipitate or exacerbate medical and/or psychiatric illnesses. Given this, primary care is an ideal point for managing sleep disorders, yet prior research shows that PCPs diagnose and/or treat sleep disorders at rates far below population prevalences. The purpose of this study was to determine the current rate of detection and treatment of sleep disorders within primary care settings.

Methods

EMR data from two health care systems was analyzed. The proportion of PCPs diagnosing and treating one or more sleep disorders was calculated (per year) for 5 years (2014-2018). Also calculated was the percent of PCP caseload diagnosed and/or treated for sleep disorders.

Results

The two systems comprised n=1021 PCPs. From 2014-2018, the proportion of PCPs diagnosing patients with sleep disorders fluctuated between 58-89%. The proportion treating sleep disorders fluctuated between 50-91%. Non-parametric one-sample run tests (SPSS) indicate these are random distributions (p>0.05). PCPs’ use of medications to treat sleep disorders is trending downward over time within one system (per linear regression, p=0.03, R-squared=0.8). Other temporal trends were not evidenced. The average percentage of diagnosed and treated patients per PCP was around 2.5% of their caseloads. Between-system differences were observed.

Conclusion

There is a profound mismatch between percentage of PCPs identifying patients with sleep disorders (60-90%) and the percentage of patient caseload diagnosed and/or treated for sleep disorders (2.5%). This suggests that the majority of PCPs are willing to assess for sleep health but do so in only a small minority of patients. These data, along with our survey data (elsewhere in this volume) suggest that the intention-action gap could be closed if PCPs were appropriately resourced.

Support

There was no funding for this study.

0464 Sleep Continuity by Neighborhood: Are There Differences?

Introduction

To our knowledge, no prior work has been conducted on whether sleep continuity disturbance (e.g., SL; WASO; EMA, etc.) varies by neighborhood. While differences on these metrics have been found by, e.g., race and socioeconomic status, it may also be that sleep continuity disturbance varies relative to where one lives and works. Accordingly, an analysis was undertaken to assess whether regional differences exist with respect to sleep continuity disturbance (SCD).

Methods

The study utilized a cross-sectional group design in an archival/community dataset that was collected in the Philadelphia area (www.sleeplessinphilly.com). This dataset (n = 2840) was comprised of adults between 18 and 89 years of age with self-reported sleep complaints (63.4% female; 36.6% male; average age 38). Study subjects who endorsed >30 minutes on >3 days/week on SL, WASO & EMA were categorized by zip code and into four regional groups: Center City (n=258); South Philadelphia (n=103); North & Northeast Philadelphia (n=400) and West Philadelphia (n=345). Contingency analyses and ANOVAS were used to assess for regional group differences.

Results

It was found that SCD rates significantly differed by region. Differences in percent endorsement by region were as follows, SL:, 64.1% (Northeast/North), 63.5 (South), 56.3% (West Philadelphia), & 48.7% (Center City); WASO: 45% (Northeast/North), 40% (South), 36.5% (West Philly), & 32.4% (Center City); EMA: 46.4% (South); 43.7 (Northeast/North); 43.7 (West Philly); 43.1 (Center City).

Conclusion

The Northeast/North region of Philadelphia had the highest rates, and center city had the lowest rates of SCD for the early part of the night (SL & WASO). Early morning SCD was most common for “South Philly and least common for Center City. Analyses are on-going in relation to other regional differences (demographic, income, crime stats, etc.) and those found to vary by region will be assessed for their predictive value.

Support

No support was provided for this abstract

0351 Sleep Continuity, Sleep-Related Daytime Dysfunction, and Problem Endorsement: Do These Vary Concordantly by Age?

Introduction

It is well documented that sleep continuity (i.e., SC [ability to initiate and/or maintain sleep]) worsens with age. It is unclear whether problem endorsement and/or daytime dysfunction show similar age-related trends. Accordingly, an analysis was undertaken to assess whether initial, middle, and/or late insomnia all exhibit age related change and whether problem endorsement and/or daytime dysfunction show comparable age-related changes.

Methods

The study utilized a cross-sectional group design in an archival/community dataset (www.sleeplessinphilly.com). This dataset (N=932) was comprised of adults between 18 and 89 years of age with self-reported sleep complaints. Participants were categorized as: Young Adults (18-29 years); Adults (30-44 years); Middle Age Adults (45-64 years); and Older Adults (65-89 years). Age groups were matched to the Older Adults group (n=233) by sex, race, and BMI. ANOVAs with Bonferroni corrections (alpha = .001), and contingency analyses were performed to assess for age group differences.

Results

It was found that, as expected, SC worsens with age but that this was limited to middle and late insomnia. Further, problem endorsement increased with age (except for SL) but sleep-related daytime dysfunction did not (except for concentration issues).

Conclusion

These results have several implications. Methodologically speaking, when evaluating the effects and/or correlates of SC, it may be wise to concomitantly assay “is this a problem for you” and “does this affect your daytime function”, as SC can occur without perceived daytime consequences, especially in older adults. Conceptually speaking, the observed discordance requires further exploration. In the past, it has been argued that sleep need is reduced in older adults. While this is a reasonable hypothesis (no need, no functional consequence), it remains to be demonstrated that older adults require less sleep.

Support

 

0868 How Do Sleep Morbidities Differ Amongst Pregnant Women, Women Who Are Intending To Conceive, And Women Who Are Not Intending To Conceive?

Introduction

Maternal sleep disturbance is common during pregnancy and is associated with adverse maternal and child outcomes, such as postpartum depression and preterm birth. The extent to which sleep disorder symptoms are normative among women of reproductive age, however, is largely unknown. The present study’s primary aim was to explore cumulative sleep morbidity and the incidence of disorder-specific symptoms among reproductive-aged women of different childbearing statuses.

Methods

Sleep morbidity variables were examined cross-sectionally among three groups of reproductive-aged nulliparous women: those 1) currently pregnant (n=148), 2) currently intending to conceive (n=233), and 3) not currently intending to conceive (n=379). All subjects self-reported sleep disorder symptoms at baseline using the Sleep Disorders Symptom Checklist-25 (SDS-CL-25). This instrument measures symptoms related to 13 sleep disorders scaled 0 (never) to 4 (> 5 days per week). Average scores were calculated for each item, each of 13 sleep disorders, and for the whole instrument (0-100).

Results

Initial results indicated that pregnant women (M=22.80, SD=11.49) had a higher rate of cumulative sleep morbidity than women who were intending to conceive (M=20.33, SD=11.14) and women who were not intending to conceive (M=20.15, SD=12.03) (p=.05). Pregnant women also had increased rates of insomnia (M pregnant=8.38, SD=3.77; M intending=6.86, SD=3.60; M not intending=6.53, SD=3.47; p<.001) and restless legs syndrome/periodic limb movement disorder (M pregnant=2.77, SD=3.05; M intending=2.02, SD=2.28; M not intending=1.99, SD=2.43; p= .004) as compared to non-pregnant women.

Conclusion

These data suggest, as is widely held, that pregnant women have greater levels of sleep disturbance than women of a common reproductive age who are currently intending to conceive or who are not currently intending to conceive. The observed sleep disturbance appears to be limited to sleep initiation and maintenance and RLS/PLMs symptomatology. Additional analyses are ongoing.

Support

Perlis & Kloss: R21HD083628; Perlis K24AG055602

0544 Reconsidering Stimulus Control: Activities in Bed Associated with Sleep-Related Outcomes

Introduction

The typical advice is that in order to avoid insomnia, people should avoid activities in bed other than sleep. Yet, activities such as reading and watching TV in bed are common.

Methods

Data were obtained from the Sleep and Health Activity, Diet, Environment, and Socialization (SHADES) Study, N=1,007 adults age 22-60. Sleep hygiene was assessed using items from the Sleep Practices and Attitudes Questionnaire (SPAQ), which asked whether respondents agree/disagree that they do the following in bed: Read, Watch TV, Eat, Work, Worry, and/or Argue. These were analyzed in relation to Insomnia Severity Index (ISI) score, Pittsburgh Sleep Quality Index (PSQI) score, Epworth Sleepiness Scale (ESS) score, Fatigue Severity Scale (FSS) score, and self-reported sleep duration (TST), sleep latency (SL), and wake after sleep onset (WASO). Covariates included age, sex, education, and income.

Results

Those that frequently engaged in activities were: reading (75%), watching TV (63%), eating (42%), working (32%), worrying (82%), and arguing (23%). Reading was associated with less WASO (B=-14min, p=0.02). Watching TV was associated with higher ISI (B=1.22, p=0.04), PSQI (B=1.04, p=0.007), and ESS (B=0.87, p=0.049), and less TST (B=-0.29, p=0.04). Eating was associated with higher ISI (B=1.75, p=0.01), PSQI (B=1.23, p=0.008), and FSS (B=4.36, p=0.002). Working was associated with higher ISI (B=1.82, p=0.019), PSQI (B=1.65, p=0.001), and ESS (B=1.78, p=0.002). Worrying was associated with higher ISI (B=7.34, p<0.0005), PSQI (B=4.40, p<0.0005), ESS (B=2.53, p=0.001), FSS (B=9.51, p<0.0005), and SL (B=19.39, p<0.0005), and less TST (B=-0.55, p=0.023). Arguing was associated with higher ISI (B=3.78, p<0.0005), PSQI (B=3.15, p<0.0005), ESS (1.47, p=0.023), and SL (B=10.97, p=0.013), and lower TST (B=-0.71, p=0.001).

Conclusion

Individuals who perform mentally distressing activities such as worrying and arguing experience especially worse sleep, and those who read in bed have fewer awakenings.

Support

The SHADES study was funded by R21ES022931. Dr. Grandner is supported by R01MD011600.

0405 Sleep Duration and Sleep Disturbance Related to Obesity, Health, Motor Vehicle Safety, and Daytime Functioning in Israel: Data From the 2017 Israel Social Survey

Introduction

Previous studies suggest the Israeli population exhibits relatively short sleep duration and experiences sleep difficulties. This analysis evaluates the relationships between habitual sleep and outcomes of interest in this population.

Methods

Data were obtained from 7,230 Israeli individuals. The sample consisted a 2017 population-based survey of households, conducted by the Israeli Bureau of Statistics. All variables were self-reported. Outcomes of interest included drowsy driving, sleep medication use, functional impairment, sleepiness, overall health, 1-year health change, and obesity. Predictors included categories of sleep duration (<=5, 6, 7, 8 [reference], or >=9 hours) and sleep disturbance in the past month (none [reference], mild [1/week], moderate [2-3/week], or severe [>3/week]). Covariates included age, sex, ethnic group, and financial status. Binary and ordinal logistic regressions were employed to evaluate the relationship between them and post-hoc analyses evaluated the relationships between subgroups.

Results

Drowsy driving was associated with <=5h, 6h, and 7h sleep duration categories, and severe sleep disturbance. The use of sleep medication use was associated with <=5h and >=9h, and all levels of sleep disturbance. Functional impairment and sleepiness were both associated with <=5h, 6h, 7h, and >=9h, and all levels of sleep disturbance. Their reported overall health was linked to sleep duration of <=5h and >=9h, and all levels of sleep disturbance. Worsening health was associated with <=5h and all levels of sleep disturbance. Obesity was associated with <=5h and severe sleep disturbance. In post-hoc analyses restricted to individuals with no sleep disturbance, habitual sleep duration was still statistically significantly related to drowsy driving, sleep medications, sleepiness, and health change.

Conclusion

Short sleep duration and sleep disturbance are associated with worse motor vehicle safety, health, and functioning in the Israeli population. Effects of sleep duration were generally maintained even for those without sleep disturbance. These results may help focus public health efforts on improving sleep health.

Support

Dr. Grandner is supported by R01MD011600

1109 Broadly Assessing Sleep Complaints In A Sample Of Patients With ADHD

Introduction

It is commonly observed in clinical settings that patients with ADHD regularly present with comorbid “sleep disturbances”. In the absence of broad based sleep disorders assessments, it is thought that this represents Delayed Sleep Phase Disorder (DSPD). Recently, a surveillance study was undertaken in a university-based, outpatient specialty clinic for adults with ADHD, by adding a comprehensive sleep disorders screener (SDS-CL-25) to the clinical intake procedures. These data were used to ascertain which sleep disorders symptoms are common in this clinical cohort.

Methods

SDS-CL-25 data were collected in 150 subjects (93/57 male/female, mean age 32.8, age range 18-79). The SDS-CL-25 is a 25 item instrument developed to screen for 13 sleep disorders at one time (Sleep Dx symptoms are endorsed on Likert-scales; 0 [never] 4 [>5x/week]). For the purposes of this study, the percentage of subjects endorsing frequent symptomatology (sum of the percent of endorsements for columns 3 & 4)was calculated per symptom. Sums of >20% were considered, a priori, to be of clinical significance.

Results

Patients endorsed: increased fatigue (59%); SL or WASO or EMA’s >30 minutes (40%; 26%; 21%, respectively); late preferred time to bed (31%); work & school limits sleep opportunity (30%); variable time to and out of bed (27%); and snoring (21%). The average percent endorsement was 15% (range 0-59%).

Conclusion

These results suggest that, consistent with clinical observations, adult patients diagnosed with ADHD frequently endorse late preferred time to bed, variable sleep wake schedules, work/school limitations on sleep opportunity, and sleep onset problems that are accompanied by daytime fatigue. This constellation of symptoms is consistent with the notion that patients with ADHD tend to have comorbid DSPD. The high prevalence of middle and late insomnia was unexpected and suggests that Insomnia Disorder (proper) may also be a feature of ADHD.

Support

No support was provided for this abstract.

0153 Patient-Defined Insomnia Severity: How Much Wakefulness is Problematic?

Introduction

While Insomnia Disorder is formally defined in the ICSD-3 and DSM-5, neither diagnostic system adopts quantitative criteria for illness severity. Interestingly, quantitative criteria are provided for frequency and chronicity (i.e., ≥ 3 days / week for ≥ 3 months). For research purposes, illness severity has long been defined using the “30 minute rule” (SL and/or WASO and/or EMA of ≥ 30 minutes is the threshold for clinical relevance). In the present analysis, this threshold was assessed for its significance to patients.

Methods

Sleep continuity disturbance (SCD; SL, WASO, and EMA) and problem endorsement data were collected from an archival/community-based sample (N = 4680; 60% female; Ages 18–89 years; www.sleeplessinphilly.com). Problem endorsement was evaluated through questions that included, “Do you consider this a problem?” after participants reported length of SL, WASO, and EMA. Problem endorsement percentages were calculated for 5 minute bins for between 0 and 65 minutes, with one additional bin for > 65 minutes. The temporal bins were compared for significant deviations using absolute (percent of subjects at 0–5 and 5–10 minutes) and moving references (last significant percent).

Results

The first temporal bin to differ from the absolute reference for SL, WASO, and EMA was the 26–30 minute bin. At this threshold, 87%, 70%, and 94% of the subjects’ identifying SL, WASO and EMA as being problematic (and was deemed statistically different from “normal” [0–10 minute values]).

Conclusion

These data suggest that the “30 minute rule” (which is of unknown provenance) roughly corresponds to the level of illness severity (lowest common threshold) identified by patients as problematic. While the threshold for SL and EMA show a clear majority, the lower percentage of subjects for WASO suggests that people are more tolerant of middle of the night wakefulness.

Support

 

1111 Do Sleep Disorder Symptom Endorsements Differ Between ADHD Subtypes?

Introduction

To date, research on differences in sleep complaints between patients with different subtypes of ADHD has been mixed. On balance, the evidence tends towards ADHD-Combined Presentation (ADHD-C) being associated with more severe sleep and sleep-related daytime complaints than ADHD-Primarily Inattentive (ADHD-I). In order to further assess this issue a surveillance study was undertaken in an active ADHD clinic by adding a comprehensive sleep disorders screener (SDS-CL-25) to the clinical intake procedures. These data were used to ascertain whether the two subtypes differ for any of 13 sleep disorders symptoms.

Methods

Subjects (n = 132; 83 male, 49 female, mean age 32.8, age range 18-79), presenting to the clinic for evaluation for ADHD were given the SDS-CL-25. The SDS-CL-25 is a 25-item instrument developed to screen for multiple sleep disorders at one time (problems are endorsed on a Likert-scale; 0 = never and 4 = more than 5x/week). Endorsements greater than 3x/week were counted as positive for the symptom and less than three days per week was considered negative.

Percent per group was compared using Chi Square Analyses. Cumulative morbidity means were also analyzed using t-tests. The subtype, ADHD-I (n=71) and ADHD-C (N=61), was established using EMR records.

Results

No significant differences between patients with ADHD-I and ADHD-C were detected.

Conclusion

The lack of finding in the present analysis may reflect a lack of difference or a failure to detect differences based on the small sample sizes or lack of statistical control for likely confounders (age, sex, illness severity or chronicity, SES status, etc.). Analyses are ongoing.

Support

No support was provided for this abstract.

1093 Population-level Suicide Ideation: Impact Of Combined Roles Of Sleep Duration, Sleep Disturbance, And Daytime Sleepiness

Introduction

Poor sleep has been shown to be related to suicide ideation and depressed mood, but population-level studies have not been done to explore the specific issues within sleep that effect mood, specifically leading to suicide ideation.

Methods

Data from adults 18 and older in the 2015-2016 National Health and Nutrition Examination Survey (NHANES) who provided complete data were used (N=5,123). Suicide ideation was recorded as the presence of thinking that “you would be better off dead” in the past 2 weeks. Sleep duration was recorded in half-hour increments and transformed to represent absolute distance from 7 hours (to model u-shaped association). Sleep disturbance was recorded as presence of “difficulty falling asleep, staying asleep, or sleeping too much” non, several days, or more than half the days of the past 2 weeks. Sleepiness was frequency feeling “overly sleepy during the day” in the past 12 months. Covariates included age, sex, race/ethnicity, and presence of depressed mood in the past 2 weeks. Additional impact of difficulty thinking/concentrating in the past 2 weeks was explored. NHANES sample weights were used in analyses.

Results

In adjusted analyses, increase likelihood of suicide ideation was associated with distance from 7hrs (OR=1.24/hr, p=0.008), sleep difficulties most of the time (OR=2.46, p=0.001), but not sleepiness. When both sleep variables were adjusted for each other, results remained significant for U-shaped sleep duration (OR=1.21/hr, p=0.02) and sleep disturbance (OR=2.31, p=0.003). These were attenuated but remained significant when difficulty thinking/concentrating was introduced; a significant sobel test (p<0.0001) suggested partial mediation, with this variable accounting for approximately 13% of the variance of the relationship to sleep.

Conclusion

In the population, improper and poor sleep was associated with a greater risk of suicide ideation.

Support

Dr. Grandner is supported by R01MD011600

1174 Assessing Sleep Disorders in Primary Care: A Provider Survey About the Importance of Sleep Health

Introduction

Conditions commonly managed by primary care providers (PCPs) such as depression, diabetes, and heart disease, commonly co-occur with sleep disorders. If PCPs could readily identify comorbid sleep disorders in this context, it may provide a pathway to more effective management of both types of disorders. Currently, it is unknown what might encourage or discourage PCPs from routinely screening their patients for sleep disorders.

Methods

PCPs from UPENN and GHS completed surveys regarding sleep health. The 30-item instrument comprised demographic, 14 VAS (0%-100%=strongly disagree-strongly agree), 4 open-ended, 3 yes/no, and 2 multiple-choice questions.

Results

Ninety-nine PCPs responded and were predominately female (61% F, 37%M, 2% other), Caucasian (81%), on-average 45yrs old (25-70) and in primary care for 16yrs (1-43). Fifty-six percent were MDs, 21%DOs, 17%PAs, and 6%NPs. PCPs rated sleep disorders as highly important for cardiopulmonary, mental, and general health (85, 84, & 83%), with no difference (per linear regression, p>0.05) according to system or provider characteristics. PCPs reported high importance for knowing about and diagnosing sleep disorders (88% & 82%) within their practices. Lower comfort levels were reported for discussing (78%) sleep disorders, overseeing/following (62%), diagnosing (60%), or treating (48%) patients. Eighty percent of PCPs stated an efficient sleep disorders screener would be useful for their practice; this perception varied (per logistic regression) according to provider credentials (Wald=0.037) and Hispanic/Latino ethnicity (Wald=0.025). PCPs reported time constraints limit their responsiveness to sleep disorders

Conclusion

A large disparity exists between the importance PCPs place on sleep disorders and their low comfort levels with following, diagnosing, and treating sleep disorders. PCPs endorsed the need to have available an efficient sleep disorders screener to use in their practice.

Support

No funding was received for this study.

The hypocretin neurotransmission system in myotonic dystrophy type 1

BACKGROUND

Patients with myotonic dystrophy type 1 (DM1) frequently have symptoms of excessive daytime sleepiness (EDS). Some patients with DM1 show sleep-onset REM, similar to that observed in narcolepsy. Narcolepsy is characterized by impaired hypocretin (Hcrt) neurotransmission.

OBJECTIVE

To test for dysregulation of Hcrt neurotransmission in a prospective cohort of patients with DM1.

METHODS

Hcrt levels in CSF were measured by radioimmunoassay. Sleep physiology was assessed by overnight polysomnography (PSG) and a multiple sleep latency test (MSLT). Splicing of Hcrt receptor 1 and 2 (HcrtR1 and HcrtR2) mRNA was examined in postmortem samples of temporal cortex.

RESULTS

Seventeen of 38 patients with DM1 reported symptoms of EDS. Among patients with DM1 with EDS who underwent PSG/MSLT, 7 of 13 showed reduced sleep latency, sleep-onset REM, or both. However, CSF Hcrt levels in DM1 (mean 277 pg/mL, n = 38) were not different from controls (mean 277 pg/mL, n = 33). Also, splicing of HcrtR1 and HcrtR2 mRNA in patients with DM1 was similar to controls.

CONCLUSIONS

Excessive daytime sleepiness and dysregulation of REM sleep occur frequently in patients with myotonic dystrophy type 1 (DM1). However, the pathophysiologic basis is distinct from narcolepsy, as patients with DM1 do not have a consistent defect of Hcrt release or receptor splicing.

Prevalence and severity of sleep disturbance in 596 cancer patients: A URCC CCOP study

9016

Background: Sleep disturbance is a prevalent and, potentially, chronic problem among cancer patients, persisting for many months and years after treatments. As part of a multi-center longitudinal survey of patients beginning cancer treatments, we prospectively investigated the prevalence and severity of self-reported sleep disturbance. Methods: 596 Cancer patients (mean age=61; 66.4%=female) receiving chemotherapy and/or radiation (37.1%=chemotherapy, 40.1%=radiation therapy, 22.8%=both) from 17 NCI CCOPs reported whether they experienced any sleep disturbance using an 11-point Likert Scale (0 = “Not present” to 10 = “As bad as you can imagine”) prior to treatments, during treatments, and 6 months after finishing treatments. A side effect level 7 was considered “severe.” Results: Sleep disruption was reported by 31.9% (median=2; 10.6% severe) at baseline, 77.2% (median=4; 28.5% severe) during treatment and 65.1% (median=2; 15% severe) at 6 months post-treatment. Repeated-measures ANOVAs revealed statistically significant treatment group (chemotherapy, radiation, or both), age (< 61 or ≥ 61 yrs), and gender by time interactions (all p<0.05). Sleep disturbance was significantly higher among survivors in the two groups receiving chemotherapy, younger survivors, and women (all p<0.05). Sleep disruption increased from baseline to post-treatment and decreased from post-treatment to 6 months post-treatment (all p<0.05). There were no significant differences between baseline and 6 months post-treatment. Conclusions: These results show that difficulties with sleep increase during cancer treatment. Patients who are at higher risk for having sleep problems are women, younger patients, and patients undergoing chemotherapy. Supported by NCI Grants U10-CA37420 and R25-CA102618

No significant financial relationships to disclose.

A comparison of placebo and no-treatment during a hypnotic clinical trial

OBJECTIVE

Sleep parameters commonly improve during placebo treatment in insomnia clinical trials. We examined whether the improvement seen with placebo was related to taking pills or other non-specific factors.

METHOD

95 insomniacs took either a placebo pill (pill+) or no pill (pill-) on nights of their choosing over 12 weeks.

RESULTS

Pills were consumed on about half of the nights. Consistent improvement was seen with reduced reported sleep latency, wakefulness after sleep onset, number of awakenings, and total sleep time over the 12 weeks for both the pill+ and pill condition. A difference between pill+ and pill- was detected only for total sleep time, and this difference favored pill+.

CONCLUSIONS

This study suggests that improvement seen during placebo treatment is more related to non-specific factors of participating in clinical trial than to pill taking behavior.

Improving compliance with nasal CPAP and vigilance in older adults with OAHS

The present study examined the efficacy of a cognitive-behavioral intervention at improving compliance with CPAP and vigilance in older adults with obstructive sleep apnea/hypopnea syndrome (OSAHS). Participants included 12 subjects who were randomized into one of two groups controlling for age, education, disease severity, and vigilance. The experimental group received two 45-min sessions designed to educate subjects on the consequences of OSAHS and the efficacy of CPAP. The control group received the same extent of therapist contact but did not receive information on OSAHS or CPAP. All subjects were administered a test of vigilance both before and after the study. Compliance data were collected using CPAP devices with internal microprocessors at were read at 1, 4, and 12 weeks after treatment initiation. The results showed that the experimental condition did not enhance compliance after 1 week of treatment but did so by the 12-week follow-up. Subjects in the experimental condition had a run time of 3.2-h per night longer than did those in the control group. Those using CPAP more regularly at 12 weeks also showed greater improvement on vigilance at follow-up. Performance on vigilance testing before the introduction of CPAP was predictive of CPAP use at 12 weeks. In conclusion, a modest cognitive-behavioral intervention may substantially increase CPAP use and vigilance in older adults.

The mesograde amnesia of sleep may be attenuated in subjects with primary insomnia

In this study, we pilot tested one of the more controversial components of the Neurocognitive Model of Insomnia; the proposition that subjects with chronic primary insomnia are better able to recall and/or recognize information from sleep onset intervals than good sleeper controls. Nine subjects participated in this pilot study, five of whom had a complaint of insomnia. The remaining four subjects were self-reported good sleeper controls. Subjects were matched for age, sex, and body mass. All subjects spent two nights in the sleep laboratory. The first night served as an adaptation night. The second night served as the experimental night during which a forced awakening and memory task was deployed. In this procedure, subjects were played single-word stimuli across four time periods: at natural sleep onset (Trial 1) and at the sleep onset transitions following three forced awakenings (Trials 2-4 from Stage 2 sleep). All subjects were awakened after about 6 h had elapsed from lights out and were tested for free recall and recognition memory for the word stimuli. The insomnia subjects, tended to identify more of the word stimuli on the recognition task (average for the four trials) and recognized significantly more of the words that were presented at sleep onset proper (Trial 1). This finding suggests that the natural mesograde amnesia of sleep may be attenuated in subjects with insomnia.

Temporal and stagewise distribution of high frequency EEG activity in patients with primary and secondary insomnia and in good sleeper controls

In the present study, we evaluate the temporal and stagewise distribution of high frequency EEG activity (HFA) in primary and secondary insomnia. Three groups (n=9 per group) were compared: primary insomnia (PI), Insomnia secondary to major depression (MDD), and good sleeper controls (GS). Groups were matched for age, sex and body mass. Average spectral profiles were created for each sleep epoch. Grand averages were created for each NREM cycle and each stage of sleep after removing waking and movement epochs and epochs containing micro or miniarousals. It was found that HFA (in terms of relative power) tends to increase across NREM cycles, occurs maximally during stage 1 and during REM sleep, and that both these effects are exaggerated in patients with PI. In addition, HFA was found to be inversely associated with Delta activity and the three groups in our study appear to exhibit characteristic Delta/Beta patterns. Our data are consistent with the perspective that HFA is related to CNS arousal to the extent that Beta/Gamma activity occurs maximally during shallow stages of sleep and maximally in subjects with PI.

Behavioral treatment of insomnia: treatment outcome and the relevance of medical and psychiatric morbidity

Recently, we undertook a case series study and found that behavior therapy for insomnia was effective as plied in the clinic setting and that the findings were similar to those in the "clinical trial" literature. In the present study, we evaluate a second set of case series data to assess (1) the replicability of our original findings, (2) if our treatment outcomes are statistically comparable to those in the literature, and (3) if medical and psychiatric morbidity influence treatment outcome. It was found that patients who completed four or more sessions of cognitive behavioral therapy for insomnia (CBT) were, on average, 33% improved. This average corresponded to a 56% reduction in wake time after sleep onset, a 34% reduction in sleep latency, a 29% increase in total sleep time, and a 13% decrease in number of awakenings per night. These findings are not significantly different from those reported in literature for both CBT and pharmacotherapy interventions. Medical and psychiatric comorbidity did not influence treatment outcome.

The diagnosis of primary insomnia and treatment alternatives

This review provides information about the diagnosis and treatment of primary insomnia. Several treatment strategies are reviewed including the use of hypnotics, naturopathic remedies and behavioral interventions. We suggest that nonpharmacologic interventions are likely to be the most safe and effective.

Beta/Gamma EEG activity in patients with primary and secondary insomnia and good sleeper controls

STUDY OBJECTIVE

Several studies have shown that patients with insomnia exhibit elevated levels of Beta EEG activity (14-35 Hz) at or around sleep onset and during NREM sleep. In this study, we evaluated 1) the extent to which high frequency EEG activity is limited to the 14-32 Hz domain, 2) whether high frequency EEG activity (HFA) is associated with discrepancies between subjective and PSG measures of sleep continuity, and 3) the extent to which high frequency EEG activity occurs in patients with primary, as opposed to secondary, insomnia.

DESIGN

Three groups (n=9 per group) were compared: Primary Insomnia, Insomnia secondary to Major Depression, and Good Sleeper Controls. Groups were matched for age, sex and body mass. Average spectral profiles were created for each NREM cycle after removing waking and movement epochs and epochs containing micro- or mini-arousals.

SETTING

Sleep Research Laboratory

PATIENTS OR PARTICIPANTS

Patients with primary and secondary insomnia

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Subjects with Primary Insomnia exhibited more average NREM activity for Beta-1 (14-20Hz), Beta-2 (20-35Hz) and Gamma activity (35-45Hz) than the other two groups (p.<.01). Group differences were also suggestive for Omega activity (45.0-125Hz) (p.<.10), with MDD subjects tending to exhibit more activity than the other groups. Correlational analyses revealed that average NREM Beta-1 and Beta-2 activity tended to be negatively correlated with subjective-objective discrepancy measures for total sleep time and sleep latency.

CONCLUSIONS

Our results confirm that Beta activity is increased in Primary Insomnia. In addition, our data suggest that high frequency activity in patients with Primary Insomnia is limited to the Beta/Gamma range (14-45 Hz), and is negatively associated with the perception of sleep.

Presleep cognitions in patients with insomnia secondary to chronic pain

This study had two primary objectives: (1) characterize the content of presleep cognitions of chronic pain patients and (2) evaluate the association between presleep cognitions and sleep disturbance. Thirty-one outpatients with benign chronic pain completed the Beck Depression Inventory, pain and sleep diaries and participated in an in vivo, presleep thought sampling procedure for 1 week in their homes. The three most frequently reported presleep cognitions were general pain-related thoughts (36%), thoughts about the experimental procedure (27%), and negative sleep-related thoughts (26%). Stepwise multiple regression analyses found the presleep thoughts pertaining to pain and environmental stimuli were significantly associated with sleep continuity, independent from the effects of depression and nightly pain severity. Pain severity was found to be positively associated with Wake After Sleep Onset Time. These results are consistent with cognitive-behavioral models of primary insomnia and suggest the content of presleep cognitive arousal may contribute to sleep disturbance secondary to pain.

Behavioral sleep medicine. An emerging subspecialty in health psychology and sleep medicine

As the knowledge base in sleep disorders medicine has broadened, a subspecialty that we will refer to as "behavioral sleep medicine" area is emerging. This article will define this subspecialty area, provide some historical context for its emergence, review issues related to specialty training and clinical practice, and suggest needs for future research.The term "behavioral sleep medicine" was selected because it clearly denoted the two fields from which our subspecialty emerged (health psychology/behavioral medicine and sleep disorders medicine). It suggests much about our approach to training, clinical practice, and research, and it appropriately implies that the field is open to PhD sleep specialists, MD sleep specialists, and other health care providers with the relevant training. Formally, behavioral sleep medicine refers to the branch of clinical sleep medicine and health psychology that: (1) focuses on the identification of the psychological (e.g. cognitive and/or behavioral) factors that contribute to the development and/or maintenance of sleep disorders and (2) specializes in developing and providing empirically validated cognitive, behavioral, and/or other nonpharmacologic interventions for the entire spectrum of sleep disorders.

EEG sleep in African-American patients with major depression: a historical case control study

This study was designed to evaluate the effect of race, specifically African-American, on electroencephalographic (EEG) sleep and clinical symptom profile in unipolar major depression. A clinical research database was used to identify appropriate subjects and a double-matched historical case-control design was implemented. African-American depression patients were double matched within protocol to Euro-American depressed patients. Age, sex, and protocol of origin were matching variables. African-American depressed patients had less total sleep, less slow wave sleep, more stage 2 sleep, longer rapid eye movement (REM) sleep latency, less REM sleep, and lower REM density than Euro-American depressed patients. African-American depressed patients did not differ from Euro-American patients in symptom severity, age of onset, number of episodes, socio-economic status, and, as planned, did not differ in age and sex distribution. Depressive symptom constellation also did not distinguish the two groups. African-American depressed patients demonstrated differences in EEG sleep profile, with less total sleep, overall lighter nonREM sleep, and relatively preserved REM sleep, despite a clinical symptom profile that did not differ from Euro-American depressed patients. The sleep profile appeared to be consonant with the sleep findings in chronic insomnia. The pathological implications of these differences remained to be explored in careful prospective studies of African-American depressed patients and in well-characterized, racially matched normal control comparisons.

Sleep quality and presleep arousal in chronic pain

This study was designed (1) to characterize the extent and nature of sleep complaints of chronic pain patients and (2) to examine the factors that predict sleep quality. A heterogeneous sample of 51 outpatients with benign, chronic pain was recruited from newspaper and pain clinic advertisements. Patients completed a variety of self-report instruments including the Multidimensional Pain Inventory, the Pittsburgh Sleep Quality Index, the Pre-Sleep Arousal Scale, and the Beck Depression Inventory. Sleep complaints were reported by 88% of the sample. Presleep cognitive arousal, rather than pain severity, was found to be the primary predictor of sleep quality.

Which depressive symptoms are related to which sleep electroencephalographic variables?

Sleep complaints and electroencephalographic (EEG) sleep abnormalities are associated with risk for new onset depression, illness severity, treatment outcome, and vulnerability for recurrence of depression. The aim of this study was to evaluate the strength of association between EEG sleep measures and depression symptoms, and to identify the variables that account for the majority of the association. Depression ratings from the Hamilton Rating Scale for Depression and the Beck Depression Inventory and polysomnographic measures were examined in 361 adult outpatients with major depressive disorder. Canonical correlation and serial multiple regression analyses were used to determine the associations between depressive symptoms and sleep measures. Canonical correlation showed a unidimensional relationship between depressive symptoms and sleep measures (R = .55, p < .05). Fifteen depression items and nine sleep measures accounted for 95% of the correlation. Depression variables encompassed a core set of mood, neurovegetative, and cognitive symptoms. Sleep variables were primarily related to delta EEG activity, and this may be reflective of impaired sleep "drive" or heightened arousal during sleep.

Psychophysiological insomnia: the behavioural model and a neurocognitive perspective

A number of paradoxes are apparent in the assessment and treatment of psychophysiological insomnia and sleep state misperception. Three of these paradoxes exist as discrepancies between polysomnographic (PSG) measures and the subjective impressions regarding sleep quality and quantity. The remaining incongruity exists largely within the objective domain. In the case of subjective-objective discrepancies, patients with insomnia: (1) frequently identify themselves as having been awake when awakened from PSG defined sleep; (2) tend to overestimate sleep latency and underestimate total sleep time as compared with PSG measures; (3) appear to derive more benefit from pharmacotherapy that can be explained by objective gains. The remaining paradox pertains to the observation that hypnotic medications, by and large, do not normalize sleep architecture or produce a more 'sleep-like' EEG. In this paper, we review possible explanations for these various paradoxes, introduce a new perspective and suggest possible research avenues. The model introduced is based on the observation that beta and/or gamma activity (which have been found to be associated with cognitive processes) is enhanced in insomnia at or around sleep onset. We propose that this kind of high frequency EEG activity may interfere with the normal establishment of sleep onset-related mesograde amnesia. As a result, the patient with insomnia maintains a level of information and/or memory processing that blurs the phenomenological distinction between sleep and wakefulness and influences retrospective judgments about sleep initiation and duration.

Sleep complaints in chronic postconcussion syndrome

This study was designed to identify the incidence of sleep complaints in 39 patients with chronic postconcussion syndrome compared to those of a control group of 27 patients with orthopedic injuries. Patients with orthopedic injuries were selected as a comparison group to control for the effects of traumatic injury or chronic pain. There were no differences in age, sex distribution, or time from injury between the patient groups. Type and frequency of sleep disturbances in a mean two-year postinjury period were evaluated. Patients with chronic postconcussion syndrome reported more difficulty in initiating and maintaining sleep at night and greater difficulty with sleepiness during the day.

Alpha sleep and information processing, perception of sleep, pain, and arousability in fibromyalgia

This study examined the relationship between alpha sleep and information processing during sleep, perception of sleep, musculoskeletal pain, and arousability in patients with fibromyalgia. Patients (n = 20) were allowed to sleep undisturbed for the first 60 minutes of the study to assess amount of alpha sleep and were classified as high or low alpha generators based on quantitative analyses of alpha activity during this period. The groups were compared for performance on two memory tasks, perceptions of polysomnographically-defined sleep and EEG arousals in response to auditory stimuli. Correlations between symptoms of fibromyalgia and alpha activity were also examined. Alpha activity during sleep in fibromyalgic patients was associated with the perception of shallow sleep and an increased tendency to arouse in relation to auditory stimuli. Alpha activity was not associated with increased memory for auditory stimuli presented during sleep, sleep state misperception, or with myalgia symptoms. Alpha sleep appears to be, electrophysiologically, a shallow form of sleep. Our results suggest that it is perceived as such phenomenologically and that it is also associated with increased arousability.

Sustained facial muscle activity during REM sleep and its correlation with depression

Recently, we proposed that the coupling of cognitive activation and diminished arousal during REM sleep may have a mood regulating effect. Conversely, increased arousal during REM sleep may be associated with mood dysregulation. In this paper, the desensitization model is described, and data are presented on the association between motor activity during REM sleep, wakefulness and severity of depression. Motor activity sleep EEG data and two measures of depressive severity (BDI and HRSD) were obtained from 23 depressed patients. BDI scores were significantly correlated with motor activity only during REM sleep. HRSD scores were correlated with motor activity only during quiet wakefulness. These findings are consistent with the theoretical perspective that dysregulation in arousal mechanisms during REM sleep may promote mood disturbance during the depressive episode.

Nonpharmacologic treatments of insomnia

Nonpharmacologic treatments that have been evaluated for insomnia are reviewed. These include sleep hygiene techniques, stimulus control instructions, sleep restriction, chronotherapy, bright light therapy, relaxation training, biofeedback, paradoxical intention, and cognitive therapy. Comparative studies of the different treatments indicate considerable overlap in effectiveness. Direct comparisons between treatments have shown stimulus control instructions to be more effective than either relaxation training or paradoxical intention. Further research is needed on the tailoring of treatments to patient needs, as are more detailed comparisons between pharmacologic and nonpharmacologic treatments.