RELAXATION TREATMENT OF PSEUDOINSOMNIA AND IDIOPATHIC INSOMNIA: AN ELECTROENCEPHALOGRAPHIC EVALUATION

Twenty-nine insomniacs underwent four consecutive sleep laboratory evaluations before and after receiving tension-release relaxation training, no-tension-release relaxation training, or no-treatment. On the basis of the discrepancy between subjective and EEG-defined measures of latency to sleep onset, subjects were classified as pseudoinsomniacs or idiopathic insomniacs. As predicted, tension-release relaxation was significantly more effective than the other two conditions on subjective sleep measures, regardless of insomnia subtype and on objective sleep measures only for idiopathic insomniacs. Subjective improvement was maintained at 12-month followup. Numerous differences between the two subtypes emerged on pretherapy and during-therapy measures distinct from the latency measures, but changes on those variables were unrelated to outcome improvement.     

A controlled comparative investigation of psychological treatments for chronic sleep-onset insomnia

A sample of physician-referred chronic insomniacs was randomly allocated to either progressive relaxation, stimulus control, paradoxical intention, placebo or no treatment conditions. Treatment process and outcome were investigated in terms of mean and standard deviation (night to night variability) measures of sleep pattern and sleep quality. Only active treatments were associated with significant improvement, but the nature of treatment gains varied. In particular, stimulus control improved sleep pattern, whereas relaxation affected perception of sleep quality. All improvements were maintained at 17 month follow-up. Results are discussed with reference to previous research and guidelines are given for clinical practice.     

Paradoxical intention in the treatment of chronic insomnia: six case studies illustrating variability in therapeutic response

The relatively small behavioural literature available contains a number of encouraging reports evidencing the effectiveness of paradoxical intention therapy as a treatment for sleep onset insomnia. This present paper contributes a further six case studies of chronic insomniacs, referred for treatment within the context of a major treatment comparison study, who were randomly allocated to receive paradoxical intention. Therapy typically lasted for 8 weeks, consisting of two 4-week phases, the first of which involved a counterdemand manipulation designed to control for demand and expectancy factors. Considerable variability in response to therapy was observed, with 3 patients obtaining a rapid reduction in sleep onset latency while the sleep pattern of the 3 other Ss was significantly exacerbated. Although 1 S from this latter group did improve after several weeks treatment, the other 2 Ss were ultimately successfully treated with progressive relaxation training having been unable to persevere with paradoxical intention. These results are discussed with reference to previous research and the consideration of individual patient characteristics.     

MMPI differences among mild and severe insomniacs and good sleepers

Past research has attempted to delineate personality differences between insomniacs and good sleepers but has failed to control for type of insomnia or severity of the disorder. The purpose of this study was to compare MMPI scores of mild and severe sleep onset insomniacs with a control group of noninsomniacs . Results demonstrated that sleep onset insomniacs, regardless of degree of severity, differed significantly from noninsomniacs ; and that mild and severe insomniacs differed from each other on only one MMPI scale.     

Belief in an Unjust World: When Beliefs in a Just World Fail

Past research has attempted to delineate personality differences between insomniacs and good sleepers but has failed to control for type of insomnia or severity of the disorder. The purpose of this study was to compare MMPI scores of mild and severe sleep onset insomniacs with a control group of noninsomniacs. Results demonstrated that sleep onset insomniacs, regardless of degree of severity, differed significantly from noninsomniacs; and that mild and severe insomniacs differed from each other on only one MMPI scale.     

Insomniacs' perceived lack of control over sleep

Abstract

It is widely assumed that insomniacs have poor self-efficacy for sleep and it is known that successful treatment is usually accompanied by improved self-efficacy. However, there has been little detailed investigation of insomniacs perceived lack of control over sleep. Insomniacs' perceived control over sleep itself is affected more than their perceived control over pre-sleep mental activity or physical tension. It was hypothesised that insomniacs would diverge from controls more in their sense that sleep was out of their control than that sleep was under their control, though this was not supported by the data. Also, there was no clear support for the idea that insomniacs' dissatisfaction with their control over sleep was the product of excessive aspirations for control. One factor that seems likely to contribute to insomniacs' lack of perceived control over sleep is that they do not have as lawful a pattern of expectations of sleep, based on their recent pattern of sleep, as normal sleepers do. Insomniacs, like non-insomniacs, were most likely to attribute poor sleep to external stresses and an over-active mind. Insomniacs showed a wide range of heightened emotional reactions to poor sleep. The implications of the results for self-regulation approaches to the treatment of insomnia are discussed.     

Behavioral treatment of insomnia in older adults: an open clinical trial comparing two interventions

Fifty-five insomniacs, 60 years or above, participated in a behavioral treatment program, comparing two interventions (sleep hygiene+stimulus control vs sleep hygiene+relaxation tape). Half of the subjects were randomized to a waiting-list condition prior to treatment. No significant changes were observed during the waiting-list period. During the treatment period however, the subjects improved on several sleep parameters, and treatment gains were maintained at a 6-month follow-up. The effects of treatment were greater for nocturnal measures (e.g. sleep onset latency and total sleep time) as compared to daytime measures (e.g. life satisfaction, daytime alertness) and not-targeted behavior (medication use). There were no differences in treatment effects for the two interventions.     

Attribution theory, insomnia, and the reverse placebo effect: a reversal of Storms and Nisbett's findings.

Storms and Nisbett found that insomniacs got to sleep faster than usual on nights when they took placebos believed to be arousal pills. Our study attempted: (a) to replicate the reverse placebo effect using a method of measurement considered more accurate than the original technique, (b) to evaluate the effect of an arousal pill therapy after therapy is discontinued, and (c) to clarify which of two hypotheses better accounts for the effect. Using 42 insomniacs, the design varied whether pills were administered (pill) or withheld (no pill) and whether or not high justification was provided for taking the pills. The high-justification-pill and the high-justification-no-pill groups were given information intended to justify their participation, while the no-justification-pill and no-pill-no-justification groups were treated like the original arousal and control groups. Instead of a decrease in latency to sleep, the no-justification-pill group but not the high-justification-pill troup displayed a typical placebo reaction on nights they took the pills. Our results cast suspicion on the original finding. The lack of response by the high-justification-pill group is discussed in terms of Bem and Kelley's views of attribution theory.     

Melatonin rhythm abnormalities and sleep disorders in the elderly

Biological aging is often associated with sleep problems and daytime napping. Complaints of difficulty in initiating and maintaining sleep, as well as daytime drowsiness, are more common in the elderly than in any other age group. This report reviews evidence that impaired melatonin secretion is associated with sleep disorders in old age. Circulating melatonin levels have been found to be significantly lower and onset and peak times have been delayed in elderly insomniacs as compared to age-matched control subjects. In view of these findings, we investigated the effects of melatonin treatment on melatonin-deficient insomnia in the elderly. From the results of our study, it seems likely that melatonin replacement therapy may be beneficial in the initiation and maintenance of sleep in this population.     

Sleep patterns and aging: comparison of older adults with and without insomnia complaints

The nature of geriatric insomnia was studied by comparing older adults with (n = 42) and without (n = 30) insomnia complaints on measures of sleep, mood, life-style, health, and sleep-requirement expectations. Elderly persons with insomnia complaints reported longer sleep latency and more frequent and longer awakenings and used sleeping aids more often than those without insomnia complaints. Nocturnal sleep time was not a reliable discriminator. Poor sleepers showed greater discrepancies between their current sleep patterns and sleep-requirement expectations than did good sleepers. Elderly insomniacs acknowledged greater symptomatology of depression and anxiety than did good sleepers. Daytime napping and physical exercise were equivalent in both groups. Medical disorders, pain conditions, and drug usage (other than sleep aids) did not distinguish the two groups. Clinical implications for the treatment of geriatric insomnia are discussed.     

The role of physiological attention-focusing in the relaxation treatment of sleep disturbance,general tension,and specific stress reaction

Three experiments comparing the effects of muscle tension-release relaxation with vs without physiological attention-focusing and no-treatment on (a) sleep disturbance, (b) general tension, and (c) a variety of time estimation, heart rate perception, and stress reaction measures, are reported. The two relaxation conditions produced equivalent reductions in latency to sleep onset reports, suggesting the importance of tension-release in the relaxation treatment of sleep disturbance. Relaxation without physiological attention-focusing was unexpectedly superior to the other relaxation condition in reducing reported daily tension, supporting Denny's (1976) hypothesis that pervasive anxiety may be a function of anxiety conditioned to relaxation-produced cues. Sleep disturbed subjects over-estimated elapsed time, and relaxation training improved accuracy of time estimation. Several additional differences between sleep and tension subjects and among the three treatment conditions on physiological activity during stress are reported and discussed.     

Vicious Cycles of Sleeplessness,Sleep Phobia,and Sleep-Incompatible Behaviours in Patients with Persistent Insomnia

Abstract

In order to study the possible role of vicious cycles of sleeplessness, sleep-incompatible behaviours, and sleep phobia in patients with persistent insomnia, 70 insomniacs were compared with 70 controls on a Sleep Behaviour Questionnaire. Although the insomniacs reported much shorter sleep time than the controls, they did not differ on the amount of time spent in bed. They reported more thinking about problems and planning in bed, but did not report more overt sleep-incompatible behaviours than the controls. The notion of sleep phobia was weakly supported, but the results clearly supported the notion of vicious cycles of sleeplessness (worries, frustration, and negative expectations about sleeplessness). In a second study, SBQ items were factor analyzed, and correlations between SBQ items and personality variables, depression, and stress measures were studied. The item that correlated most strongly with degree of reported sleeping problems referred to negative expectations about sleeplessness. Factor analysis identified four factors: negative expectations, worrying, frustration over sleeplessness, and sleep phobia, with negative expectations accounting for most of the variance.     

Clinical validation of a sleep assessment device

We have previously reported on the use of a sleep assessment device (SAD) with non-insomniac subjects. The SAD works by generating a brief, soft tone about every 10 min throughout the night and tape recording verbal responses to these cues. The sleep patterns reconstructed from the night's tape recordings proved highly concordant with EEG records. The present study tested the SAD against the EEG standard in 20 nights of monitoring chronic insomniacs. No significant differences were found between the SAD and EEG records with respect to sleep latency, duration of awakenings during the night, total sleep time and sleep efficiency percentage. The EEG detected many more very brief awakenings during the night than did the SAD due to the continuous monitoring by the former. The SAD proved to be a non-intrusive measure of sleep according to three independent measures. The usefulness of the SAD as a measure of sleep in the natural environment was discussed.     

The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: implementation and evaluation of a sleep clinic in general medical practice

Chronic insomnia is a very common clinical condition which may respond well to non-pharmacological treatment. Indeed, the literature supports the efficacy of cognitive behaviour therapy (CBT). However, there has been no substantial study of clinical effectiveness. Since insomniacs typically present in general medical practice this is a crucial gap in the outcome research. This study, therefore, specifically investigated the clinical effectiveness of CBT delivered by Health Visitors (primary care nurses) trained as therapists. One hundred and thirty-nine insomniacs (mean age 51 yr) were randomised to CBT or Self-Monitoring Control (SMC) in a controlled trial. CBT comprised six group sessions (n=4 to 6 patients). After the controlled phase, SMC patients entered deferred treatment (CBT-DEF), allowing both treatment replication and long-term outcome to be investigated for a sizeable, treated sample. Repeated measures ANOVAs demonstrated superiority of CBT over SMC in substantially reducing sleep latency and wakefulness during the night. CBT-DEF replicated similar effects and maintained improvement was observed in both groups one year later. Furthermore, total sleep increased significantly during follow-up and 84% of patients initially using hypnotics remained drug-free. Results suggest that CBT administered by Health Visitors offers a clinically effective treatment for insomnia.     

Circaseptan aspects of self-assessed sleep protocols covering 70 nights on 33 clinically healthy persons

This study aimed to describe quantitatively some changes in sleep behavior. During 70 consecutive nights, 28 women and 3 men, 30 to 40 years of age and presumably clinically healthy, recorded the time of each awakening. Time of falling asleep were estimated from markings at 10-min. intervals from the times of lying down to sleep as an indication that the subject had not yet fallen asleep. Sleep duration and an index of effective sleep derived therefrom were analyzed by rhythmometric methods. On a group basis, anticipated components with periods of 1 and 0.5 wk., synchronized with the social schedule, were detected with statistical significance. Until long-term polysomnographic monitoring can readily cover the week automatically rather than only one or a few daily sleep spans, the self-monitoring of sleep behavior, yielding the circaseptan endpoints derived herein, may serve as a cost-effective tool in sleep research. By virtue of their relative simplicity, they could be part of a protocol designed to assess pharmacologic or nonpharmacologic interventions of sleep disturbance aimed at restoring undisturbed sleep.     

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.     

REM Sleep Bout Duration and Frequency in PTSD

The few pharmacological treatments shown to be effective in reducing sleep disturbance in posttraumatic stress disorder (PTSD) might work through normalization of rapid eye movement (REM). However, evidence of REM sleep disturbance in PTSD has been inconsistent and the definition of REM bout has varied as well. In this study, we compared polysomnographic findings in adults with PTSD to both normal sleepers and insomniacs. We found no differences between those with and without PTSD on REM bout frequency or duration. We did, however, find gender differences within our PTSD sample as consistent with a previous review suggesting that males with PTSD are more likely to demonstrate REM sleep disturbance. Consensus on REM bout definition is needed, in addition to studies powered to detect gender differences.     

Validity and reactivity of a system of self-monitoring suicide ideation

The present study describes the rationale and validation of a self-monitoring approach for suicide ideation. A sample of 49 severely ideating 18- to 24-year-old college students volunteering for a treatment study for chronic ideators served as subjects. A three-item self-monitoring scale designed to assess the strength, duration, and level of control relative to suicide ideation was designed and utilized. Positive correlations with previously validated measures of suicide ideation support the validity of the use of self-monitoring. In addition, positive relationships with measures of depression and hopelessness provide evidence of concurrent validity. There was no evidence that self-monitoring and concomitant increased attention to ideation increased suicidality. In fact, decreases were noted in measures of suicide ideation following a 2-week period of self-monitoring. Together these findings support the addition of self-monitoring to the list of dependent measures for addressing suicidal behavior.     

Effectiveness of Cognitive-Behavioral Insomnia Treatment in a Community Sample of Older Individuals: More Questions than Conclusions

Effectiveness of two modified stimulus control insomnia interventions plus daily sleep self-monitoring for managing insomnia was investigated in a community sample of older adults. Significant post intervention improvement was observed in both interventions as well as in a self-monitoring only control condition. This unexpected finding led us to question the role of self-monitoring as a potential mediator of therapeutic change. Therefore, we compared long-term follow-up data from treated participants to data from similarly poor sleepers who only completed the questionnaire battery at Pre-test and long term follow-up, with no intervening treatment or self-monitoring. Both groups of poor sleepers reduced their reported amount of nocturnal wakefulness. However, only treated participants improved on their perceived frequency of insomnia episodes and insomnia-related distress. Our findings have implications both for the definition and the treatment of insomnia.     

Effects of progressive relaxation and meditation on cognitive and somatic manifestations of daily stress

Meditation and progressive relaxation were compared with a self-monitoring control as treatments for symptoms of stress. Subjects were recruited from advertisements in local newspapers and received five sessions of training. All subjects self-monitored stress symptoms throughout the study and had their behavior rated weekly by a spouse/roommate. The progressive relaxation and meditation treatments resulted in a significant reduction of stress symptomatology over time. Little evidence was generated for differential effects of treatments.