- Email: [email protected]
Pre-sleep arousal, unhelpful beliefs and maladaptive sleep behaviors as mediators in cognitive behavior therapy for insomnia
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Abstracts / Sleep Medicine 14S (2013) e93–e164
the consequent sleep deprivation have several adverse effects on patient care and residents themselves. The aim of this study was to determine sleep quality of residents in a major teaching hospital in Iran and investigate the key factors contributing to poor sleep quality. Materials and methods: 250 residents from different surgical and medical specialties were enrolled in the study. Demographic questionnaire along with the Persian version of Pittsburgh Sleep Quality Index (PSQI) were administered to the subjects. Results: Mean Global PSQI score was 6.06 ± 2.68, which is higher than the mean score of general urban adult population of Tehran (5.06, CI: 4.9–5.1). 55.8% of residents had a global PSQI score greater than 5. We tested a model predicting global PSQI score using age, age of the youngest child, academic level, number of overnight duties, average daytime duty extent, total time of extra shifts and specialty as predictive factors. Number of overnight duties was the only significant predictor of PSQI score in this model (R2 = 0.890, df = 7, F = 5.78, p-value = 0.036). Conclusion: A great percentage of residents had poor sleep quality. Number of overnight duties was the key factor contributing to poor sleep quality. Our findings support the need for duty hour reform in residency programs in Iran. Acknowledgement: This project was funded in part by Tehran University of Medical Sciences.
the mean AIS score of these 22 participants improved from 12.9 to 7.9 (SD = 3.6) at 3–4 weeks post introduction of IMT. Furthermore an analysis of the PSQI components revealed participant improvement as follows: 45.5% on daytime dysfunction, 44% on sleep efficiency, 39% on sleep latency, 38% on sleep quality, 34% on sleep duration, 21% on decreased medication use. Thus a substantial number of participants improved, and the improvements were substantial and critical. Not only did 65% of participants improve, on average they improved to a point of clinical significance (AIS < 10). Sleep quality improved (latency, efficiency and daytime dysfunction) and there was a trend towards decreased medication use. The implications of these observations are far reaching indeed if confirmed in future research. Conclusion: Compared to the other major meditation therapy developed to date (MBT-I), IMT is easier to teach and learn, less time invasive and less demanding for the practitioner and professional, produces a palpable reaction during the first session and has demonstrated improved nocturnal sleep and daytime function at 3–4 weeks post introduction. It can be considered the ultimate wind down routine prior to bedtime and be used in conjunction with other behavior and pharmaceutical treatments. Acknowledgements: The mentorship and opportunity offered by Drs. Colin Shapiro and Henry Moller, Sleep Research Laboratory and Sleep and Alertness Clinic, Toronto, Ontario, Canada.
http://dx.doi.org/10.1016/j.sleep.2013.11.363
http://dx.doi.org/10.1016/j.sleep.2013.11.364
Introducing insomnia meditation therapy: a novel behavioural intervention for insomnia S. Jain 1, G. Shapiro 2 1 Sleep and Alertness Clinic, Canada 2 Sleep Research Laboratory, Canada
Pre-sleep arousal, unhelpful beliefs and maladaptive sleep behaviors as mediators in cognitive behavior therapy for insomnia R. Sunnhed, M. Jansson-Fröjmark Department of Psychology, Stockholm University, Sweden
Introduction: Insomnia is a common condition, which is often trivialized by treating physicians. Primary Insomnia is widely viewed as a disorder of underlying inappropriate hyper-arousal interfering with sleep. Pharmaceutical treatments are effective during their duration of use but one needs to be cautious with potential adverse effects. Behavioral interventions maintain their efficacy long after the treatment period but their use is limited for a variety of reasons including the significant time involvement. There has been growing interest in alternative and complementary therapies with much of their appeal in their ability to be used in conjunction with or instead of conventional pharmaceutical therapies. Insomnia Meditation Therapy was developed during a Sleep Medicine fellowship at the University of Toronto as an easy to learn, brief behavioral intervention. Learning Objectives: (1). Review current evidence for underlying hyperarousal as it relates to Insomnia; (2) Become familiar with a novel meditation intervention specifically targeting hyperarousal; and (3) Review promising preliminary clinical results and ongoing future research. Materials and methods: Thirty-four participants had three instructional sessions of meditation in a group format over the course of a month during 2011–2012. Each session lasted 45 min and incrementally taught breathing exercises, a technique of meditative imagery (MI) and a Non-Judgmental Awareness (NJA) meditation. Participants were asked to practice once during the day and immediately prior to bedtime for 20–30 min each time. The impact of IMT was assessed by validated questionnaires, AIS and PSQI. In addition the seven components of the PSQI were independently evaluated to determine which aspect of sleep quality improved. Results: The results showed that 65% (N = 22) participants’ improved as assessed by scores on both the AIS and PSQI. Specifically
Introduction: The purpose with the investigation was to examine whether improvements in pre-sleep arousal, unhelpful beliefs about sleep, and maladaptive sleep behaviors mediate the outcomes in inperson CBT-I. Materials and methods: Thirty participants with chronic insomnia previously involved in a randomized controlled trial testing cognitive behavioral therapy versus a waitlist participated. At pretreatment and post-treatment, participants completed questionnaires and sleep diaries assessing pre-sleep arousal, unhelpful beliefs about sleep, maladaptive sleep behaviors, insomnia severity, dysfunction, anxiety, depression, and subjective sleep parameters. Outcome measures were re-administered at a 3-month follow-up. Results: The results indicated that decreases in pre-sleep cognitive arousal mediated the effect on dysfunction, and that decreases in pre-sleep somatic arousal had a mediating effect on sleep quality. Reductions in unhelpful beliefs mediated the treatment effect on insomnia severity, dysfunction, and depression. Decreases in bedtime variability mediated the outcome on insomnia severity, and reductions in time in bed had a mediating effect on total wake time and sleep quality. Noteworthy is also that improvements in the outcomes could be attributed to reductions in the mediators (50–70% of the variance). Neither rise time variability nor napping mediated the improvements. Conclusion: These findings are clearly supportive of cognitivebehavioral models of insomnia by highlighting pre-sleep arousal, unhelpful beliefs about sleep, and maladaptive sleep behaviors as mediators in the treatment of insomnia. The results are also important for clinical work and for testing new approaches in future research.
Abstracts / Sleep Medicine 14S (2013) e93–e164
Acknowledgements: We would like to express our appreciation to Sparbankstiftelsen Nya for funding and to the two audiology clinics in Örebro and Karlstad for recruitment. http://dx.doi.org/10.1016/j.sleep.2013.11.365
Behavior therapy singly and combined with constructive worry for insomnia: Cognitive and behavioral processes as mediators R. Sunnhed, M. Jansson-Fröjmark Department of Psychology, Stockholm University, Sweden
Introduction: The purpose with the investigation was to examine whether improvements in insomnia-related worry and time in bed mediate the outcomes in in-person CBT-I. Materials and methods: A randomized, controlled design was used, including a two-week baseline, a four-week intervention phase [sleep restriction and stimulus control (BT) or sleep restriction and stimulus control plus constructive worry (BT + CW)], and a twoweek follow-up. Thirty-one patients with primary insomnia participated. At pretreatment and mid-treatment, participants completed questionnaires and sleep diaries assessing insomnia-related worry and time in bed. At pretreatment and follow-up, outcome measures (insomnia severity, dysfunction, and subjective sleep parameters) were administered. Results: The results indicated that decreases in insomnia-related worry mediated the effect on insomnia severity and sleep quality. Reductions in time in bed mediated the treatment effect on dysfunction and total wake time. Noteworthy is also that improvements in the outcomes could be attributed to reductions in the mediators (21–60% of the variance). Conclusion: These findings provide support for cognitive-behavioral models of insomnia by highlighting insomnia-related worry and time in bed as mediators in the treatment of insomnia. The results are also important for clinical work and for testing new approaches in future research. Acknowledgements: We would like to express our appreciation to Mikael Bermås and Andreas Kjellén for collaboration on recruiting the participants. http://dx.doi.org/10.1016/j.sleep.2013.11.366
Beyond sleep duration: distinct sleep dimensions are associated with obesity in children and adolescents D. Jarrin 1, J. Mcgrath 2, C. Drake 3 1 Université Laval, Canada 2 Concordia University, Canada 3 Henry Ford Hospital, Canada
Introduction: Short sleep duration is recognized as a significant risk factor in childhood obesity; however, the question as to how sleep contributes to the development of obesity remains largely unknown. The majority of pediatric studies have relied on sleep duration as the exclusive measure of sleep; this insular approach may be misleading given that sleep is a dynamic multidimensional construct beyond sleep duration, including sleep disturbances and patterns. Although these sleep dimensions partly overlap, it is necessary to determine their independent relation with obesity, which in turn, may inform a more comprehensive understanding of putative pathophysiological mechanisms linking sleep and obesity. The aim of the present study was to investigate whether sleep dimensions
e159
including sleep duration, disturbances, and patterns were individually associated with obesity, independent of multiple covariates. The second objective was to examine whether sleep disturbances and patterns were independently associated with obesity, after adjusting for sleep duration. Materials and methods: Participants included 240 healthy children and adolescents (Mage = 12.60, SD = 1.98; 45.8% females). Anthropometric measures included measured waist and hip circumference, body mass index Z-score, and percent body fat. Subjective sleep measures included sleep duration, sleep disturbances, sleep quality, and sleep patterns from youth- and parental report. Results: Youth with larger adiposity and body composition measures reported poorer sleep quality (bavg = 0.14, p < 0.01), more sleep disturbances (bavg = 0.13, p < 0.05), and showed a delayed sleep phase pattern (bavg = 0.15, p < 0.05), independent of age, sex, pubertal status, physical activity, screen time, socioeconomic status, and sleep duration. Shorter sleep duration was significantly associated with obesity; however, this link was attenuated after adjustment of covariates. Conclusion: The results suggest that sleep measures beyond duration may more precisely capture influences that drive the negative association between sleep and obesity, and thus, yield more robust associations. As such, future studies are needed to better understand how distinct sleep dimensions confer risk for childhood obesity. Acknowledgements: This work was made possible through funding support from the Canadian Institutes of Health Research (MOP89886;OCO79897; 127383) and the Fonds de la recherche en santé du Québec (16965). http://dx.doi.org/10.1016/j.sleep.2013.11.367
Does vulnerability to stress-related insomnia predict future incident and persistent insomnia among good sleepers? D. Jarrin, I. Chen, H. Ivers, C. Morin Université Laval, Canada
Introduction: Clinical and research evidence suggest that individuals who are more prone to experience situational insomnia under stressful conditions may also be at greater risk to eventually develop chronic insomnia. While there is substantial cross-sectional data on the association between heightened vulnerability to stress-related insomnia and sleep disturbances (i.e., low sleep efficiency, sleep fragmentation), there is limited data on its predictive value. The aim of the present study was to prospectively evaluate whether heightened vulnerability to stress-related insomnia was associated with increased risk of incident and persistent insomnia in a population-based sample of good sleepers. Materials and methods: Data were derived from a larger epidemiological study conducted in Québec, Canada. Participants were 1449 adults (Mage = 47.4 yrs, SD = 15.1; 41.2% male) without insomnia at baseline and evaluated four times over 3-years. Vulnerability to stress-related insomnia was measured using the Ford Insomnia Response to Stress Test (FIRST). The Life Experience Survey was used to assess the frequency and perceived impact of positive and negative events that occurred in the past year. Incident insomnia was defined as a case reporting insomnia symptoms or syndrome at any of the follow-up evaluations (non-cumulative). Persistent insomnia was defined as a case reporting insomnia symptoms or syndrome at least twice during the follow-up evaluations. Results: Of the sample, 91.7% completed the 6-month follow-up, 87.8% completed the 1-year follow-up, 84.1% completed the 2-year follow-up, and 71.5% completed the 3-year follow-up. After controlling for age, sex, depressive symptoms, and stressful events and per-
Abstracts / Sleep Medicine 14S (2013) e93–e164
the consequent sleep deprivation have several adverse effects on patient care and residents themselves. The aim of this study was to determine sleep quality of residents in a major teaching hospital in Iran and investigate the key factors contributing to poor sleep quality. Materials and methods: 250 residents from different surgical and medical specialties were enrolled in the study. Demographic questionnaire along with the Persian version of Pittsburgh Sleep Quality Index (PSQI) were administered to the subjects. Results: Mean Global PSQI score was 6.06 ± 2.68, which is higher than the mean score of general urban adult population of Tehran (5.06, CI: 4.9–5.1). 55.8% of residents had a global PSQI score greater than 5. We tested a model predicting global PSQI score using age, age of the youngest child, academic level, number of overnight duties, average daytime duty extent, total time of extra shifts and specialty as predictive factors. Number of overnight duties was the only significant predictor of PSQI score in this model (R2 = 0.890, df = 7, F = 5.78, p-value = 0.036). Conclusion: A great percentage of residents had poor sleep quality. Number of overnight duties was the key factor contributing to poor sleep quality. Our findings support the need for duty hour reform in residency programs in Iran. Acknowledgement: This project was funded in part by Tehran University of Medical Sciences.
the mean AIS score of these 22 participants improved from 12.9 to 7.9 (SD = 3.6) at 3–4 weeks post introduction of IMT. Furthermore an analysis of the PSQI components revealed participant improvement as follows: 45.5% on daytime dysfunction, 44% on sleep efficiency, 39% on sleep latency, 38% on sleep quality, 34% on sleep duration, 21% on decreased medication use. Thus a substantial number of participants improved, and the improvements were substantial and critical. Not only did 65% of participants improve, on average they improved to a point of clinical significance (AIS < 10). Sleep quality improved (latency, efficiency and daytime dysfunction) and there was a trend towards decreased medication use. The implications of these observations are far reaching indeed if confirmed in future research. Conclusion: Compared to the other major meditation therapy developed to date (MBT-I), IMT is easier to teach and learn, less time invasive and less demanding for the practitioner and professional, produces a palpable reaction during the first session and has demonstrated improved nocturnal sleep and daytime function at 3–4 weeks post introduction. It can be considered the ultimate wind down routine prior to bedtime and be used in conjunction with other behavior and pharmaceutical treatments. Acknowledgements: The mentorship and opportunity offered by Drs. Colin Shapiro and Henry Moller, Sleep Research Laboratory and Sleep and Alertness Clinic, Toronto, Ontario, Canada.
http://dx.doi.org/10.1016/j.sleep.2013.11.363
http://dx.doi.org/10.1016/j.sleep.2013.11.364
Introducing insomnia meditation therapy: a novel behavioural intervention for insomnia S. Jain 1, G. Shapiro 2 1 Sleep and Alertness Clinic, Canada 2 Sleep Research Laboratory, Canada
Pre-sleep arousal, unhelpful beliefs and maladaptive sleep behaviors as mediators in cognitive behavior therapy for insomnia R. Sunnhed, M. Jansson-Fröjmark Department of Psychology, Stockholm University, Sweden
Introduction: Insomnia is a common condition, which is often trivialized by treating physicians. Primary Insomnia is widely viewed as a disorder of underlying inappropriate hyper-arousal interfering with sleep. Pharmaceutical treatments are effective during their duration of use but one needs to be cautious with potential adverse effects. Behavioral interventions maintain their efficacy long after the treatment period but their use is limited for a variety of reasons including the significant time involvement. There has been growing interest in alternative and complementary therapies with much of their appeal in their ability to be used in conjunction with or instead of conventional pharmaceutical therapies. Insomnia Meditation Therapy was developed during a Sleep Medicine fellowship at the University of Toronto as an easy to learn, brief behavioral intervention. Learning Objectives: (1). Review current evidence for underlying hyperarousal as it relates to Insomnia; (2) Become familiar with a novel meditation intervention specifically targeting hyperarousal; and (3) Review promising preliminary clinical results and ongoing future research. Materials and methods: Thirty-four participants had three instructional sessions of meditation in a group format over the course of a month during 2011–2012. Each session lasted 45 min and incrementally taught breathing exercises, a technique of meditative imagery (MI) and a Non-Judgmental Awareness (NJA) meditation. Participants were asked to practice once during the day and immediately prior to bedtime for 20–30 min each time. The impact of IMT was assessed by validated questionnaires, AIS and PSQI. In addition the seven components of the PSQI were independently evaluated to determine which aspect of sleep quality improved. Results: The results showed that 65% (N = 22) participants’ improved as assessed by scores on both the AIS and PSQI. Specifically
Introduction: The purpose with the investigation was to examine whether improvements in pre-sleep arousal, unhelpful beliefs about sleep, and maladaptive sleep behaviors mediate the outcomes in inperson CBT-I. Materials and methods: Thirty participants with chronic insomnia previously involved in a randomized controlled trial testing cognitive behavioral therapy versus a waitlist participated. At pretreatment and post-treatment, participants completed questionnaires and sleep diaries assessing pre-sleep arousal, unhelpful beliefs about sleep, maladaptive sleep behaviors, insomnia severity, dysfunction, anxiety, depression, and subjective sleep parameters. Outcome measures were re-administered at a 3-month follow-up. Results: The results indicated that decreases in pre-sleep cognitive arousal mediated the effect on dysfunction, and that decreases in pre-sleep somatic arousal had a mediating effect on sleep quality. Reductions in unhelpful beliefs mediated the treatment effect on insomnia severity, dysfunction, and depression. Decreases in bedtime variability mediated the outcome on insomnia severity, and reductions in time in bed had a mediating effect on total wake time and sleep quality. Noteworthy is also that improvements in the outcomes could be attributed to reductions in the mediators (50–70% of the variance). Neither rise time variability nor napping mediated the improvements. Conclusion: These findings are clearly supportive of cognitivebehavioral models of insomnia by highlighting pre-sleep arousal, unhelpful beliefs about sleep, and maladaptive sleep behaviors as mediators in the treatment of insomnia. The results are also important for clinical work and for testing new approaches in future research.
Abstracts / Sleep Medicine 14S (2013) e93–e164
Acknowledgements: We would like to express our appreciation to Sparbankstiftelsen Nya for funding and to the two audiology clinics in Örebro and Karlstad for recruitment. http://dx.doi.org/10.1016/j.sleep.2013.11.365
Behavior therapy singly and combined with constructive worry for insomnia: Cognitive and behavioral processes as mediators R. Sunnhed, M. Jansson-Fröjmark Department of Psychology, Stockholm University, Sweden
Introduction: The purpose with the investigation was to examine whether improvements in insomnia-related worry and time in bed mediate the outcomes in in-person CBT-I. Materials and methods: A randomized, controlled design was used, including a two-week baseline, a four-week intervention phase [sleep restriction and stimulus control (BT) or sleep restriction and stimulus control plus constructive worry (BT + CW)], and a twoweek follow-up. Thirty-one patients with primary insomnia participated. At pretreatment and mid-treatment, participants completed questionnaires and sleep diaries assessing insomnia-related worry and time in bed. At pretreatment and follow-up, outcome measures (insomnia severity, dysfunction, and subjective sleep parameters) were administered. Results: The results indicated that decreases in insomnia-related worry mediated the effect on insomnia severity and sleep quality. Reductions in time in bed mediated the treatment effect on dysfunction and total wake time. Noteworthy is also that improvements in the outcomes could be attributed to reductions in the mediators (21–60% of the variance). Conclusion: These findings provide support for cognitive-behavioral models of insomnia by highlighting insomnia-related worry and time in bed as mediators in the treatment of insomnia. The results are also important for clinical work and for testing new approaches in future research. Acknowledgements: We would like to express our appreciation to Mikael Bermås and Andreas Kjellén for collaboration on recruiting the participants. http://dx.doi.org/10.1016/j.sleep.2013.11.366
Beyond sleep duration: distinct sleep dimensions are associated with obesity in children and adolescents D. Jarrin 1, J. Mcgrath 2, C. Drake 3 1 Université Laval, Canada 2 Concordia University, Canada 3 Henry Ford Hospital, Canada
Introduction: Short sleep duration is recognized as a significant risk factor in childhood obesity; however, the question as to how sleep contributes to the development of obesity remains largely unknown. The majority of pediatric studies have relied on sleep duration as the exclusive measure of sleep; this insular approach may be misleading given that sleep is a dynamic multidimensional construct beyond sleep duration, including sleep disturbances and patterns. Although these sleep dimensions partly overlap, it is necessary to determine their independent relation with obesity, which in turn, may inform a more comprehensive understanding of putative pathophysiological mechanisms linking sleep and obesity. The aim of the present study was to investigate whether sleep dimensions
e159
including sleep duration, disturbances, and patterns were individually associated with obesity, independent of multiple covariates. The second objective was to examine whether sleep disturbances and patterns were independently associated with obesity, after adjusting for sleep duration. Materials and methods: Participants included 240 healthy children and adolescents (Mage = 12.60, SD = 1.98; 45.8% females). Anthropometric measures included measured waist and hip circumference, body mass index Z-score, and percent body fat. Subjective sleep measures included sleep duration, sleep disturbances, sleep quality, and sleep patterns from youth- and parental report. Results: Youth with larger adiposity and body composition measures reported poorer sleep quality (bavg = 0.14, p < 0.01), more sleep disturbances (bavg = 0.13, p < 0.05), and showed a delayed sleep phase pattern (bavg = 0.15, p < 0.05), independent of age, sex, pubertal status, physical activity, screen time, socioeconomic status, and sleep duration. Shorter sleep duration was significantly associated with obesity; however, this link was attenuated after adjustment of covariates. Conclusion: The results suggest that sleep measures beyond duration may more precisely capture influences that drive the negative association between sleep and obesity, and thus, yield more robust associations. As such, future studies are needed to better understand how distinct sleep dimensions confer risk for childhood obesity. Acknowledgements: This work was made possible through funding support from the Canadian Institutes of Health Research (MOP89886;OCO79897; 127383) and the Fonds de la recherche en santé du Québec (16965). http://dx.doi.org/10.1016/j.sleep.2013.11.367
Does vulnerability to stress-related insomnia predict future incident and persistent insomnia among good sleepers? D. Jarrin, I. Chen, H. Ivers, C. Morin Université Laval, Canada
Introduction: Clinical and research evidence suggest that individuals who are more prone to experience situational insomnia under stressful conditions may also be at greater risk to eventually develop chronic insomnia. While there is substantial cross-sectional data on the association between heightened vulnerability to stress-related insomnia and sleep disturbances (i.e., low sleep efficiency, sleep fragmentation), there is limited data on its predictive value. The aim of the present study was to prospectively evaluate whether heightened vulnerability to stress-related insomnia was associated with increased risk of incident and persistent insomnia in a population-based sample of good sleepers. Materials and methods: Data were derived from a larger epidemiological study conducted in Québec, Canada. Participants were 1449 adults (Mage = 47.4 yrs, SD = 15.1; 41.2% male) without insomnia at baseline and evaluated four times over 3-years. Vulnerability to stress-related insomnia was measured using the Ford Insomnia Response to Stress Test (FIRST). The Life Experience Survey was used to assess the frequency and perceived impact of positive and negative events that occurred in the past year. Incident insomnia was defined as a case reporting insomnia symptoms or syndrome at any of the follow-up evaluations (non-cumulative). Persistent insomnia was defined as a case reporting insomnia symptoms or syndrome at least twice during the follow-up evaluations. Results: Of the sample, 91.7% completed the 6-month follow-up, 87.8% completed the 1-year follow-up, 84.1% completed the 2-year follow-up, and 71.5% completed the 3-year follow-up. After controlling for age, sex, depressive symptoms, and stressful events and per-