A cognitive-behavioral therapy for sleep-maintenance insomnia in older adults.

Older adults (3 men, 4 women, aged 55 to 68 years) with chronic sleep-maintenance insomnia were treated sequentially with relaxation therapy (RT) and then with a cognitive-behavioral therapy (CBT) specifically designed for alleviating sleep maintenance problems. Sleep diaries and an objective measure of sleep, the sleep assessment device, showed only modest improvements in measures of wake time after sleep onset, sleep efficiency, and night-to-night sleep variability following RT. However, significant improvements in these measures were observed following CBT and at a 3-month follow-up. These findings, considered in conjunction with previous reports, suggest that CBT specifically addresses factors that sustain sleep maintenance complaints. Additional trials of CBT with larger samples are warranted.

Polysomnographic assessment of DIMS: empirical evaluation of its diagnostic value.

This investigation examined the diagnostic value of polysomnography (PSG) for evaluating disorders of initiating and maintaining sleep (DIMS). The sample consisted of 100 outpatients who presented to the Duke Sleep Disorders Center with a complaint of chronic insomnia. All patients were given comprehensive medical, psychiatric, behavioral, and ambulatory PSG evaluations. Sleep disorder diagnoses were assigned using the criteria of the Association of Sleep Disorders Centers. Overall, PSG yielded important diagnostic information in 65% of the sample: 34% were given a primary sleep disorder diagnosis that was heavily dependent on PSG data [periodic movements of sleep (PMS) = 25%, apnea = 3%, and subjective insomnia = 6%]; 15% were given a secondary diagnosis of one of these three disorders; and PSG ruled out suspected PMS in 9% and sleep apnea in 7% of the sample. Patients greater than 40 years of age had a significantly higher rate of positive PSG findings than younger patients. Using only the clinical exam, two experienced sleep clinicians were able to predict only 14 of 25 PMS cases and one of three cases of sleep apnea. Based on these data, we suggest using PSG routinely with older insomniacs and with younger patients who fail initial treatment.

Two methods of scoring sleep with the Oxford Medilog 9000: comparison to conventional paper scoring.

This study evaluated two methods of scoring taped polysomnographic data directly on the Medilog 9000 scanner: (a) screen-by-screen scoring, and (b) rapid screen scoring. Sixteen overnight polysomnograms recorded on Medilog 9000 recorders were scored using the above two methods and were also printed on paper for conventional paper scoring. Interscorer agreement was 87.8% for paper scoring, 85.5% for screen-by-screen scoring, and 84.2% for rapid screen scoring. Comparison of screen-by-screen scoring with paper scoring revealed small absolute deviations and correlations of r greater than 0.90 for all sleep parameters, with the exception of brief (less than 2 min) awakenings (r = 0.69). Rapid screen scoring resulted in slightly lower correlations and greater deviations from paper scoring on several sleep parameters, but appeared acceptable for most clinical purposes and greatly reduced the required scoring time. Although some statistically significant differences between scoring methods were observed, the size of effect was small and of doubtful clinical importance. These findings suggest that polysomnographic data recorded on Medilog 9000 recorders can be reliably and accurately scored on the Medilog scanner, obviating the laborious task of printing the taped data on paper.

Biofeedback to enhance psychophysiological effects of imagery.

Unlike most applications of biofeedback, the outcome goal and the aim of the present investigation was to increase arousal by the provision of feedback. The ability to generate psychophysiological arousal during noxious imagery may be therapeutically beneficial to individuals receiving emotive imagery therapies, and in the present study we evaluated biofeedback as a means of correcting psychophysiological deficits in imagery. Thirty psychophysiologically unreactive undergraduates were randomly assigned to skin-resistance-level biofeedback, false-feedback, or no-feedback conditions for six sessions of assessment and treatment. The methodology controlled for placebo, practice, and initial value effects. Significant increases in skin resistance level, heart rate, and frontalis electromyography accrued to the biofeedback group but not the control groups, and these gains persisted when biofeedback was withdrawn. Subjective measures showed no changes. The results support the usefulness of biofeedback as a remedy for imagery underarousal.

Treatment of sleep-maintenance insomnia in older adults: sleep period reduction, sleep education, and modified stimulus control.

We evaluated a behavioral treatment package consisting of sleep period restriction, sleep education, and modified stimulus control in the treatment of sleep-maintenance insomnia in older adults. A multiple baseline design was used with 4 chronic insomniac subjects, ages 59, 65, 65, and 72. Sleep diaries and an objective behavioral measure of sleep were used to monitor improvement. Results revealed clinically significant reductions in time awake after sleep onset in 3 subjects, coincident with the initiation of treatment. These improvements were maintained at 2- and 6-month follow-ups. The 4th subject showed little improvement; however, a polysomnogram conducted on this subject at the end of the study revealed a fragmented sleep pattern secondary to periodic movements of sleep (nocturnal myoclonus). These encouraging but preliminary results call for further controlled evaluations of the efficacy of this behavioral treatment package for sleep-maintenance insomnia. The importance of conducting polysomnographic studies on elderly insomniacs is discussed.

Cluster analysis of insomniacs' MMPI profiles: relation of subtypes to sleep history and treatment outcome.

The Minnesota Multiphasic Personality Inventory (MMPI) profiles of 100 insomniacs who presented for treatment at a university medical center were analyzed by a hierarchical clustering procedure. This analysis revealed two major personality types that accounted for 88% of the sample. The two types referred to as "Type 1" and "Type 2" insomniacs differed significantly in regard to sleep history questionnaire responses and responsivity to treatment. MMPI scales and sleep history questionnaire items suggested that Type 1 insomniacs were less defended, more aroused/activated, and had sleep histories characterized by more childhood sleep problems and greater difficulties with sleep-disruptive cognitions than did Type 2 patients. Further, Type 1 patients had a poorer response to behavioral treatment as measured by change in sleep-onset latency than did Type 2 patients. These results suggest that the MMPI may be useful in identifying distinctive personality subgroups among insomniacs. Treatment implications are discussed, and mechanisms underlying the group differences are considered.

Maintenance of relaxation-induced blood pressure reductions: the importance of continued relaxation practice.

This study examined the long-term importance of continued relaxation practice in the maintenance of relaxation-induced blood pressure reductions. An ABAB withdrawal-reinstatement design was employed with two hypertensive subjects. An objective, unobtrusive measure of home relaxation practice was used to monitor compliance. Subject 1 showed substantial reductions in systolic and diastolic blood pressure during 3 months of relaxation practice, followed by a 60% return to baseline during withdrawal, and a subsequent decrease with reinstatement of relaxation. Subject 2 showed a pattern similar to that of Subject 1 for systolic blood pressure, though the trend for diastolic pressure was unclear owing to a marginal treatment response. These preliminary data suggest that continued relaxation practice may be an important factor in the maintenance of relaxation-induced blood pressure reductions.

Blood volume pulse biofeedback treatment of chronic cluster headache.

Behavioral interventions shown to be clinically effective in the treatment of migraine headache have generally not been employed for cluster headache. Herein, we report on the treatment of a severe case of chronic cluster headache with a common method of migraine treatment, temporal blood volume pulse (BVP) biofeedback. The patient was a 61-year-old male, medically diagnosed as suffering from chronic cluster headaches for over 20 years. Following an 18-day baseline, 14 BVP biofeedback sessions were conducted over a 7-week period. By the last 2 weeks of treatment, there was a 70% reduction in daily headache frequency and a 45% decrease in headache severity. Improvement was maintained at 1, 3, 6, 12, and 21 months follow-up. Large decreases in the consumption of migraine abortives , narcotic analgesics, and antiemetics were also observed. These encouraging results call for further evaluation of the efficacy of BVP biofeedback treatment of chronic cluster headache.

An integrated blood volume pulse biofeedback system for migraine treatment.

A blood volume pulse (BVP) biofeedback system is described that integrates BVP amplitude to provide a signal appropriate for auditory feedback. In comparison to binary BVP feedback methods, this integrated system offers the advantages of continuous feedback and increased scoring ease. The validity of this system was established by correlating the integrated BVP output with trough-to-peak measurements of the raw BVP signal during unassisted relaxation and temporal BVP biofeedback with eight migraine headache patients. Within-subject correlations of the integrated and raw BVP outputs ranged from .82 to .98 (means = .95). Although the integrated method admits unwanted BVP changes in rate, correlation analyses showed this confound factor to be small. Increments in biofeedback training effects were observed during the treatment course. Substantive migraine relief was achieved by the end of treatment and therapeutic gains were maintained at 1-year follow-up. In conclusion, it appears that this method successfully presents continuous auditory feedback from an integrated BVP signal resulting in therapeutic benefits to migraineurs.