Insomnia characteristics and clinical correlates in Operation Enduring Freedom/Operation Iraqi Freedom veterans with post-traumatic stress disorder and mild traumatic brain injury: an exploratory study.

BACKGROUND: There is limited data on chronic insomnia in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, in whom post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) often co-exist. Our aim was to compare sleep characteristics of three groups of OEF/OIF veterans: (1) healthy sleepers (HS), (2) those with insomnia associated with PTSD and mTBI (PTSD-mTBI), and (3) those with insomnia associated with PTSD alone. METHODS: Consecutive veterans with insomnia complaints (> 6 months) were recruited over 6 months from the Miami VA Post Deployment clinic. Participants completed a sleep disorders clinical interview, medical history, and questionnaires about insomnia, sleepiness, pain, fatigue, depression, PTSD, and health-related quality of life. They underwent polysomnography (PSG) with 2 weeks of actigraphy (ACT) and sleep diaries. RESULTS: There were no differences in demographics or most questionnaire responses between PTSD and PTSD-mTBI groups. Subjective daytime sleepiness was significantly greater in PTSD-mTBI subjects compared with HS and PTSD participants. Significant co-morbid sleep disorders were noted in insomnia patients. PSG and ACT wake after sleep onset was significantly shorter in PTSD-mTBI subjects as compared with PTSD participants. CONCLUSION: Insomnia patients with PTSD-mTBI were subjectively sleepier despite spending less time awake during the night than PTSD subjects, possibly as a consequence of head trauma.

Does cognitive-behavioral insomnia therapy alter dysfunctional beliefs about sleep?

STUDY OBJECTIVES: This study was conducted to exam the degree to which cognitive-behavioral insomnia therapy (CBT) reduces dysfunctional beliefs about sleep and to determine if such cognitive changes correlate with sleep improvements. DESIGN: The study used a double-blind, placebo-controlled design in which participants were randomized to CBT, progressive muscle relaxation training or a sham behavioral intervention. Each treatment was provided in 6 weekly, 30-60-minute individual therapy sessions. SETTING: The sleep disorders center of a large university medical center. PARTICIPANTS: Seventy-five individuals (ages 40 to 80 years of age) who met strict criteria for persistent primary sleep-maintenance insomnia were enrolled in this trial. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Participants completed the Dysfunctional Beliefs and Attitudes About Sleep (DBAS) Scale, as well as other assessment procedures before treatment, shortly after treatment, and at a six-month follow-up. Items composing a factor-analytically derived DBAS short form (DBAS-SF) were then used to compare treatment groups across time points. Results showed CBT produced larger changes on the DBAS-SF than did the other treatments, and these changes endured through the follow-up period. Moreover, these cognitive changes were correlated with improvements noted on both objective and subjective measures of insomnia symptoms, particularly within the CBT group. CONCLUSIONS: CBT is effective for reducing dysfunctional beliefs about sleep and such changes are associated with other positive outcomes in insomnia treatment.

Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial.

CONTEXT: Use of nonpharmacological behavioral therapy has been suggested for treatment of chronic primary insomnia, but well-blinded, placebo-controlled trials demonstrating effective behavioral therapy for sleep-maintenance insomnia are lacking. OBJECTIVE: To test the efficacy of a hybrid cognitive behavioral therapy (CBT) compared with both a first-generation behavioral treatment and a placebo therapy for treating primary sleep-maintenance insomnia. DESIGN AND SETTING: Randomized, double-blind, placebo-controlled clinical trial conducted at a single academic medical center, with recruitment from January 1995 to July 1997. PATIENTS: Seventy-five adults (n = 35 women; mean age, 55.3 years) with chronic primary sleep-maintenance insomnia (mean duration of symptoms, 13.6 years). INTERVENTIONS: Patients were randomly assigned to receive CBT (sleep education, stimulus control, and time-in-bed restrictions; n = 25), progressive muscle relaxation training (RT; n = 25), or a quasi-desensitization (placebo) treatment (n = 25). Outpatient treatment lasted 6 weeks, with follow-up conducted at 6 months. MAIN OUTCOME MEASURES: Objective (polysomnography) and subjective (sleep log) measures of total sleep time, middle and terminal wake time after sleep onset (WASO), and sleep efficiency; questionnaire measures of global insomnia symptoms, sleep-related self-efficacy, and mood. RESULTS: Cognitive behavioral therapy produced larger improvements across the majority of outcome measures than did RT or placebo treatment. For example, sleep logs showed that CBT-treated patients achieved an average 54% reduction in their WASO whereas RT-treated and placebo-treated patients, respectively, achieved only 16% and 12% reductions in this measure. Recipients of CBT also showed a greater normalization of sleep and subjective symptoms than did the other groups with an average sleep time of more than 6 hours, middle WASO of 26.6 minutes, and sleep efficiency of 85.1%. In contrast, RT-treated patients continued to report a middle WASO of 43.3 minutes and sleep efficiency of 78.8%. CONCLUSIONS: Our results suggest that CBT represents a viable intervention for primary sleep-maintenance insomnia. This treatment leads to clinically significant sleep improvements within 6 weeks and these improvements appear to endure through 6 months of follow-up.

Psychometric comparisons of the standard and abbreviated DBAS-10 versions of the dysfunctional beliefs and attitudes about sleep questionnaire.

OBJECTIVE: To evaluate the psychometric properties of the DBAS-10, a recently proposed abbreviated version of the Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS). POPULATION: Two hundred and eleven (69 normal sleepers; 142 insomnia suffers) middle-aged and older adults (age 40-79 years) drawn from two separate cohorts of research volunteers. METHOD: Volunteers in the first cohort (69 normal sleepers; 69 insomnia sufferers) completed the full DBAS on one occasion. Volunteers in the second cohort (73 insomnia sufferers) completed the full DBAS prior to treatment and at multiple subsequent time points to assess treatment-related changes. A series of statistical tests were conducted with one or both cohorts to investigate the comparability of the DBAS-10 and full DBAS, the internal consistency of each instrument, the factor structure of the DBAS-10, and the validity of this instrument. RESULTS: Statistical findings showed that the DBAS-10 correlated highly with the full DBAS, had respectable internal consistency, effectively discriminated normal sleepers from insomnia sufferers, and detected cognitive changes resulting specifically from CBT intervention. Although factor analysis empirically identified three conceptually meaningful DBAS-10 subscales, the subscale structure varied somewhat from previous factor analytic findings with this instrument. CONCLUSIONS: The DBAS-10 generally appears to have very acceptable psychometric properties although subscales previously proposed for this instrument may vary across research populations. Nonetheless, results encourage the use of this instrument in studies concerned with the nature and treatment of sleep-disruptive cognitions.

How many nights are enough? The short-term stability of sleep parameters in elderly insomniacs and normal sleepers.

Temporal stability is an important fundamental quality when measuring sleep parameters, yet it has been infrequently assessed. Generalizability theory was used to estimate the short-term temporal stability of five variables commonly used to characterize insomnia: sleep onset latency, total sleep time, wake after sleep onset, time in bed, and sleep efficiency. Estimates were calculated for 32 elderly primary insomniacs and 32 elderly normal sleepers, both in the lab and at home, using both sleep logs and polysomnography (PSG). A week of recording using either PSG or sleep logs was typically sufficient to achieve adequate stability (defined as G coefficient of at least 0.80) with some notable exceptions: (a) when using log-derived measures with insomniacs, a 3-week average was necessary for wake after sleep onset and (b) more than a 2-week average was necessary for sleep onset latency. Because of the substantial commitment involved in the physiological recording of sleep, alternative forms of aggregation are considered with the intent of improving temporal stability.

The significance and management of persistent primary insomnia: the past, present and future of behavioral insomnia therapies.

Persistent primary insomnia (PPI) is a prevalent and potentially serious condition that compromises the functioning, health status, and quality of lives of millions of individuals around the world. This condition is typically perpetuated by a host of psychological and behavioral mechanisms that often require behavioral interventions. Nonetheless, all too commonly, practitioners underestimate the seriousness of this condition or rely too heavily on symptom focused sedative hypnotic therapy for its treatment. Herein we briefly review the epidemiology of PPI and consider the inadequacies of sedative hypnotics for treating this disorder. Subsequently, we provide rationale for the use of behavioral interventions with this condition and we describe the gradual evolution of the currently available behavioral insomnia treatments and consider promising recent developments such as the emergence of cognitive-behavioral and specially tailored, patient-specific approaches. In closing, we consider the potential usefulness of a combined pharmacological/behavioral intervention for PPI and present a number of important research questions to address in future studies of the behavioral insomnia therapies.