Updates in Behavioral Sleep Medicine 2018 relaxation, and rescripting therapy; hypnosis; lucid dreaming therapy; progressive deep muscle relaxation; sleep dynamic therapy; self-exposure

Behavioral Sleep Medicine 2018 Update

Donna Arand, PhD, DABSM, FAASM

Society of Behavioral Sleep Medicine

September 16-17, 2018

Conflict of Interest Disclosures Speaker: 1. I do not have any potential conflicts of interest to disclose, OR

2. I wish to disclose the following potential conflicts of interest

Details of Potential Conflict

Grant/Research Support

Consultant

Speakers’ Bureaus

Financial support

Other

3. The material presented in this lecture has no relationship with any of these potential conflicts, OR

4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:

1.

2.

3.

Outline

I. Guidelines, Recommendations and Legislation

II. Infants, adolescents and college students

III. Treatment of Insomnia

IV. Understanding Insomnia

Guidelines Recommendations and Legislation

AASM Position Paper for Treatment of Nightmare Disorder

• Recommended for PTSD-associated nightmares and nightmare disorder: image rehearsal therapy.

• May be used for PTSD-associated nightmares: cognitive behavioral therapy; cognitive behavioral therapy for insomnia; eye movement desensitization and reprocessing; exposure, relaxation, and rescripting therapy; the atypical antipsychotics olanzapine, risperidone and aripiprazole; clonidine; cyproheptadine; fluvoxamine; gabapentin; nabilone; phenelzine; prazosin; topiramate; trazodone; and tricyclic antidepressants.

• May be used for nightmare disorder: cognitive behavioral therapy; exposure, relaxation, and rescripting therapy; hypnosis; lucid dreaming therapy; progressive deep muscle relaxation; sleep dynamic therapy; self-exposure therapy; systematic desensitization; testimony method; nitrazepam; prazosin; and triazolam.

• Not recommended for treatment of nightmare disorder: clonazepam and venlafaxine.

Morgenthaler TI, Auerbach S, Casey KR, Kristo D, Maganti R, Ramar K, Zak R, Kartje R. Position paper for the treatment of nightmare disorder in adults: an American Academy of Sleep Medicine position paper. J Clin Sleep Med. 2018;14(6):1041–1055.

AASM Clinical Practice Guidelines for use of Actigraphy in Insomnia

No recommendations only Conditional suggestions for clinician use (lower degree of certainty)

• Use actigraphy to estimate sleep parameters in adult patients with insomnia disorder (Conditional) • Significant large mean differences between sleep logs and actigraphy in TST, SL and SE • Small differences between actigraphy and PSG in TST, SL

• Use actigraphy in the assessment of pediatric patients with insomnia disorder. (Conditional) • Significant large mean differences between sleep logs and actigraphy for TST and WASO

• Use actigraphy in assessment of adult patients with circadian rhythm sleep-wake disorder (Conditional) • Significant large mean differences between sleep logs and actigraphy for sleep onset and termination

• Use actigraphy in assessment of pediatric patients with circadian rhythm sleep-wake disorder (Conditional) • Significant large mean sleep difference between sleep logs and actigraphy in TST

Smith MT, McCrae CS, Cheung J, Martin JL, Harrod CG, Heald JL, Carden KA. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2018;14(7):1231–1237.

CDC reports insufficient sleep is common in middle school and high school students

Anonymous, voluntary, school-based paper and pencil questionnaire (Youth Risk Behavior Survey) during regular class period

• Nationally about 58% of middle school students and 73% of high school students get insufficient sleep on school nights

• 50-64% of middle school students (n=52,000; 9 states) get < 9 hrs (KY -64%)

• 61-82% of high school students in grades 9-12 (n=14,000; 30 states) get <8 hrs (WVA -82%)

CDC - Short Sleep Duration Among Middle School and High School Students. Weekly, Jan 26,2018, 67, 85-90

58%

42%

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< 9 h

> 9 h

73%

27%

High School

< 8 h

> 8 h

California law would require middle school and high school to start no earlier than 8:30 am

• Law was passed by legislature and waiting for Governor’s signature

• Start time law SB 328 would be effective July 1, 2021

8:30

8

Economic Cost of Inadequate Sleep

• Estimated cost of inadequate sleep in Australia for 2016-17 and related to costs in similar economies using national surveys and databases.

• Overall cost of inadequate sleep is $45.21 billion • Direct cost was $17.88B and indirect was $27.33B

• $160 million for sleep disorders

• David Hillman, Scott Mitchell, Jared Streatfeild, Chloe Burns, Dorothy Bruck, Lynne Pezzullo; The economic cost of inadequate sleep, Sleep,

Volume 41, Issue 8, 1 August 2018,

Infants, adolescents and college students

Early Nighttime Parental Interventions and Infant Sleep Regulation Across the First Year

• Objective: To investigate how sleeping arrangement and 2 types of nighttime interventions(non distress and distress) at 1 and 3 months are associated with infants’ sleep development across the first 9 months.

• Method: • Participants: 107 families with solitary or cosleeping infants

• Design: observation and survey at 1, 3, and 9 months

• Measures: • Solitary and cosleeping infants

• # distress-initiated wakings (DIW)

• # non-distress initiated wakings (NDIW) (parents’ behaviors to non-distressed vocalizations or while infants were asleep)

Voltaire, ST, Teti, DM. Early Nighttime Parental Interventions and Infant Sleep Regulation Across the First Year. Sleep 2018, July13.

Parental Interventions and Infant Sleep Regulation

• Results • Infant night wakings decreased over time • Non-distress initiated interventions moderated by sleep arrangement

• Solitary sleeping infants with higher levels of NDIW showed less steep decline in wakings compared to solitary infants with low NDIW

• Higher DIW at 1 and 3 months resulted in steeper decrease in night wakings for both solitary and cosleeping infants.

• Conclusion • Responding to nighttime distress before 3 months predicts better infant sleep • Not responding to non-distress before 3 months predicts better sleep • Parental interventions after 3 month does not have similar impact • Very early patterns of nighttime parenting may organize infant sleep sleep

regulation

Voltaire, ST, Teti, DM. Early Nighttime Parental Interventions and Infant Sleep Regulation Across the First Year. Sleep 2018, July13

Midday Napping and Neurocognitive Function in Early Adolescents

• Participants: 363 chinese adolescents (12 + 0.38 years)

• Method: self-reported midday napping, nighttime sleep duration and sleep quality, computerized neurocognitive battery (accuracy and reaction time)

• Xiaopeng Ji, Junxin Li & Jianghong Liu (Feb 2018) The Relationship Between Midday Napping And Neurocognitive Function in Early Adolescents, Behavioral Sleep Medicine

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=2ahUKEwia2YzW8avdAhVl64MKHZVHB0UQjRx6BAgBEAU&url=http://ciricara.com/2012/09/07/lucunya-siswa-di-china-tidur-siang-bersama-di-sekolah-foto/posisi-tidur-yang-rapi/&psig=AOvVaw3_s6GyxWw3-sCLEBs2Ju_1&ust=1536512594883907

Napping and Neurocognitive in Early Adolescents

• Results • 64% took >3 naps per week • 70% took naps over 30 minutes • Ss with frequent or longer naps reported significantly better night sleep quality

• Frequent nappers (5-7d/week) had significantly better accuracy on sustained attention and nonverbal reasoning, faster reaction times on spatial memory

• Naps of any length resulted in faster reaction time compared to non-nappers • Moderate duration nappers (31-60 min) had both faster speeds and greater accuracy

Conclusion: There is an association between habitual napping and neurocognitive function in early adolescents. Naps 31-60 min seemed best for speed and accuracy.

Xiaopeng Ji, Junxin Li & Jianghong Liu (Feb 2018) The Relationship Between Midday Napping And Neurocognitive Function in Early Adolescents, Behavioral Sleep Medicine, DOI:

Sleep Hygiene Index as a Screening Tool in Nigerian Students

• Purpose: To determine characteristics and usefulness of the sleep

hygiene index in Nigerian undergraduate students

• Methods • Participants: 348 students randomly divided in two prior to factor analysis

• Measures: SHI, PSQI, ESS, Morningness Eveningness Questionnaire (MEQ)

Seun-Fadipe CT, Aloba OO, Oginni OA, Mosaku KS. Sleep hygiene index: psychometric characteristics and usefulness as a screening tool in a sample of nigerian undergraduate students. J Clin Sleep Med. 2018;14(8):1285–1292

Sleep Hygiene Index

• Results of SHI: • SHI Internal consistency was .64 • Significant negative correlation with MEQ (r=-0.17) • Significant positive correlation with PSQI (r=0.89) • Significant positive correlation with ESS (r=0.29) • Exploratory factor analysis in group 1 yielded 3 factors • Corroborative factor analysis in group 2 • Cutoff score of 16 on SHI had sensitivity of .77 and specificity of 0.47 to identify

students experiencing poor sleep quality

• Conclusion: SHI has satisfactory psychometric properties for evaluating sleep hygiene and as a screening instrument for poor sleep quality among Nigerian undergraduate students.

Seun-Fadipe CT, Aloba OO, Oginni OA, Mosaku KS. Sleep hygiene index: psychometric characteristics and usefulness as a screening tool in a sample of nigerian undergraduate students. J Clin Sleep Med. 2018;14(8):1285–1292

Acceptability of Smartphone Applications for Improving Sleep Behavior in Low Income and Minority Adolescents

• Purpose: to determine acceptability and components to motivate engagement

• Participants: N=27 (age 14-18) low income and ethnically diverse group

• Method: • Three focus groups

• Specific feedback on two commercial sleep promoting apps from 10 participants who had used one on their smart phone prior to interview, thematic analysis

Mirja Quante, Neha Khandpur, Emily Z. Kontos, Jessie P. Bakker, Judith A. Owens & Susan Redline (2018) A Qualitative Assessment of the Acceptability of Smartphone Applications for Improving Sleep Behaviors in Low-Income and Minority Adolescents, Behavioral Sleep Medicine, DOI: 10.1080/15402002.2018.1432483

Acceptability of Smartphone Sleep Apps

• Results: • Barriers identified

• reluctance to follow schedule on weekends • concern about parting with electronics at bedtime

• Intrigued by idea but skeptically they could adopt sleep hygiene practices • More interested in making changes on weekdays than on weekends • Feedback on 2 sleep apps not targeting adolescents was positive with good

adherence and engagement and perceived health benefits

• Conclusion • Need to adapt sleep hygiene apps to targeted populations and consider social and

cultural factors • Importance of platform, setting and messenger to deliver info to adolescents

Mirja Quante, Neha Khandpur, Emily Z. Kontos, Jessie P. Bakker, Judith A. Owens & Susan Redline (2018) A Qualitative Assessment of the Acceptability of Smartphone Applications for Improving Sleep Behaviors in Low-Income and Minority Adolescents, Behavioral Sleep Medicine, DOI: 10.1080/15402002.2018.1432483

Insomnia Treatment

Exposure, Relaxation and Rescripting Therapy (ERRT) for trauma-related nightmares • Objective: To conduct a dismantling study of exposure, relaxation and

rescripting therapy for nightmares

• Method • Participants (n=70) reported mean of 6 traumatic events,

mean 30 nightmares/mos, mean nights with nightmares was 4 • Design:

• Randomized to 2 conditions • ERRT with nightmare exposure and rescripting (EX) n=37, Exposure 30 min in 1 session

• ERRT without nightmare exposure and rescripting (NEX) n=33

• follow-up at 1 week, 3 months and 6 months post treatment

• Measures: nights with nightmares, nightmares per week and nightmare severity • Secondary measures: insomnia, depression, fear of sleep, PTSD, sleep quality

• Pruiksman KE,Cranston CC, Rhudy JL, Micol RL, Davis JL. Randomized controlled trial to dismantle exposure, relaxation and rescripting therapy for trauma-related nightmares. Psychological Truama: Theory, Research, Practice and Policy, 2018, Jan; 10(1), 67-75.

ERRT for Trauma for Nightmares

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ruiksman KE,Cranston CC, Rhudy JL, Micol RL, Davis JL. Randomized controlled trial to dismantle exposure, relaxation and rescripting therapy for trauma-related nightmares. Psychological Truama: Theory, Research, Practice and Policy, 2018, Jan; 10(1), 67-75.

ERRT for Trauma Related Nightmares

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Pruiksman KE,Cranston CC, Rhudy JL, Micol RL, Davis JL. Randomized controlled trial to dismantle exposure, relaxation and rescripting therapy for trauma-related nightmares. Psychological Truama: Theory, Research, Practice and Policy, 2018, Jan; 10(1), 67-75.

ERRT for Trauma Related Nightmares

• Results: • ERRT with and without nightmare exposure significantly improved outcomes (nights

with nightmares, nightmares per week, nightmare severity) • Both conditions significantly improved on fear of sleep, sleep quality, insomnia

severity, daytime sleepiness, PTSD symptom severity and depression severity. • Significant main effect for time for all variables • No difference between groups at any point

Conclusions: ERRT with and without nightmare exposure and rescripting can significantly alleviate nightmare and related distress.

Pruiksman KE,Cranston CC, Rhudy JL, Micol RL, Davis JL. Randomized controlled trial to dismantle exposure, relaxation and rescripting therapy for trauma-related nightmares. Psychological Truama: Theory, Research, Practice and Policy, 2018, Jan; 10(1), 67-75

Aerobic Exercise vs CBT-I in Cancer Patients

• Objective: Access the efficacy of 6-week home based aerobic exercise program (EX) compared to 6-week self-administered CBT-I

• Method: • Participants: 41 patients (78% F, mean age 57) with various types of Cancer and insomnia

(ISI>8) • Design: randomized controlled trial, repeated measures

• Groups: Exercise (EX) (n-20) and CBT (n=21) • Testing: pre- and post-treatment, 3 and 6 month follow-up

• Measures: • ISI • PSQI • sleep diaries (SOL, WASO, TWT and SE)

Mercier J, Ivers H, Savard J. A non-inferiority randomized controlled trial comparing a home-based aerobic exercise program to a self administered CBT-I in cancer patients. Sleep 2018, Jul 25

Exercise vs CBT-I in Cancer Patients

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Exercise vs CBT-I in Cancer Patients by Patient Preference

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• Results • Exercise and CBT-I significantly improved ISI, PSQI and most sleep diary parameters at FU

(significant main effect of time) • Exercise was statistically inferior to CBT-I at post treatment based on ISI • Exercise was non-inferior at follow-up • Objective actigraphy data did not significantly differ between groups • General persistence of sleep difficulties in CBT-I and EX with remission rates of 30% and 35%

respectively post treatment and at follow-up

• Conclusions: • Exercise and CBT-I significantly improved sleep • CBT-I remains treatment of choice in CA-related insomnia, although exercise has some

beneficial effects


Zero-time exercise on inactive adults with Insomnia Disorder: pilot RCT

• Objective: To evaluate the effects of lifestyle-integrated zero-time exercise on insomnia in inactive adults with insomnia disorder

• Method: • Participants- 37 physically inactive adults (49.9 +13.6 years, 91.9%F)

with insomnia disorder from community

• Design: Random controlled trial • ZTEx (n-18) attended two 2-hr training lesson on ZTEx & practiced daily for 8 weeks

• Sleep hygiene education (SHE) (n=19) attended two 2-hr lessons on same schedule

• Measures: ISI, actigraphy, sleep dairy • Wing-Fai Yeung, Agnes Yuen-Kwan Lai,Fiona Yan-Yee Ho, Lorna Kwai-Ping Suen,Ka-Fai Chung, Janice Yuen-Shan Ho, Lai-Ming Ho, Branda Yee-

Man Yu,Lily Ying-Tung Chan, Tai-Hing Lam. Effects of Zero-time Exercise on inactive adults with insomnia disorder: A pilot randomized controlled trial. SleepMedicine, 2018.

Zero-time Exercise in Insomnia

• Results: • ZTEx had lower ISI scores than SHE with large between group effect size of 0.94-

1.10 at weeks 2,4,6,8 but difference was non-significant at 8 weeks.

• No difference in sleep diary or actigraphy

• 83% finished ZTEx training and

• 78% did ZTEx >5 days per week for 8 weeks

Conclusion: Simple and brief ZTEx training has high acceptability and compliance and effectively reduced ISI in inactive adults with Insomnia.

Wing-Fai Yeung, Agnes Yuen-Kwan Lai,Fiona Yan-Yee Ho, Lorna Kwai-Ping Suen,Ka-Fai Chung, Janice Yuen-Shan Ho, Lai-Ming Ho, Branda Yee-Man Yu,Lily Ying-Tung Chan, Tai-Hing Lam. Effects of Zero-time Exercise on inactive adults with insomnia disorder: A pilot randomized controlled trial. SleepMedicine, 2018.

Comparative Treatments for Insomnia and Sleep Quality in Hot Flashes

• Purpose: Assess interventions for insomnia in women with vasomotor symptoms (VMS)

• Method: • Design: Pooled data from 4 RCT n=546 peri and

postmenopausal F with ISI >12, >14 VMS/week. • Interventions: escitalopram 10-20 mg/d, yoga, aerobic exercise, 1.8g/d

omega 3 fatty acids, 17-beta estradiol 0.5mg.d, venlafaxine XR 75mg.d, and CBT-I

• Outcomes: ISI, PSQI at baseline, 4 weeks, 8 weeks and some at 12 weeks

Katherine A Guthrie et al. Sleep, Volume 41, Issue 1, 1 January 2018, zsx190. Effects of Pharmacologic and Nonpharmacologic Interventions on Insomnia Symptoms and Self-reported Sleep Quality in Women With Hot Flashes: A Pooled Analysis of Individual Participant Data From Four MsFLASH Trials

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Treatments for Insomnia and Sleep Quality in Hot Flashes

• Results: • CBT-I produced the greatest reduction in ISI from baseline compared to controls -5.2 points

(95% CI -7.0 to -3.4) • Exercise and venlafaxine were similar (-2.1 and -2.3) • CBT-I produced largest reduction in PSQI of -2.7 points (-3.9 to -1.5) • Yoga, exercise, estradiol, venlafaxine and escitalopram produced significant decrease of 1.2-

1.6 points • Omega-3 supplements did not improve insomnia symptoms

Conclusion: Results support the recommendation for CBT-I as a first line treatment in healthy midlife women with insomnia symptoms and moderately bothersome VMS.


CBT-I and Neuropsychological Functioning in Older Adults

with Mild Cognitive Impairment

• Purpose: Determine if CBT-I improves sleep and cognitive function in older adults with mild cognitive impairment

• Methods: • 6 session CBT-I

• 2 groups – • CBT-I (n=14)

• Active control (n=14)

• Neuropsychological battery at baseline, post-treatment and 4 month FU

Cassidy-Eagel E, Siebern A, Unti L, Glassman J, O’Hara R. Neuropsychological Functioning in Older Adults with Mild Cognitive

Impairment and Insomnia Randomized to CBT-I or Control Group Clin Gerontol, 2018 Mar-Apr;41(2):136-144.

CBT-I and Neuropsychological Functioning

• Results: • significant improvement in sleep • a significant change on a key measure of executive functioning sub task of inhibition

(Condition 3 of D-KEF Color-Word Interference Test), • a positive trend on the inhibition-switching task (p < .10;) Condition 4 of D-KEF Color-

Word Interference Test), • no change in a measure of verbal memory (HVLT-R Delayed Recall) compared with

the active control

• Conclusion: CBT-I has potential to improve sleep and cognitive function in older adults with MCI

Cassidy-Eagel E, Siebern A, Unti L, Glassman J, O’Hara R. Neuropsychological Functioning in Older Adults with Mild Cognitive Impairment and Insomnia Randomized to CBT-I or Control Group Clin Gerontol, 2018 Mar-Apr;41(2):136-144.

CBT for Older Adults with Insomnia and Depression

• Purpose: To determine if CBT-I is effective for older adults with comorbid insomnia and depression and compare CBT- I to CBT-I plus mood strategies (CBT-I+)

• Methods: • Participants: n=72 (56% F, age 75 +7) with comorbid insomnia & depression DX

based on DSM-5, clinical interviews; ISI and GDS >10) • Exclusions: cognitive impairment, changes in psychotropic meds in 4 wks, high risk, in ECT or

psychotherapy

• Design: • 8-week RCT within community mental health services • 3 conditions in group therapy, 60-90min (CBT-I, CBT-I+, Psychoeducation control group) • No demographic or sleep and mental health characteristics differences between groups

• Measures: • ISI, Geriatric Depression Scale at pre, post, FU (weeks 0, 8, 30 respectively)

• Paul Sadler, Suzanne McLaren, Britt Klein, Jack Harvey, Megan Jenkins; Cognitive behavior therapy for older adults with insomnia and depression: a randomized controlled trial in community mental health services, Sleep, Volume 41, Issue 8, 1 August 2018

CBT-I in Insomnia and Depression

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Paul Sadler, Suzanne McLaren, Britt Klein, Jack Harvey, Megan Jenkins; Cognitive behavior therapy for older adults with

insomnia and depression: a randomized controlled trial in community mental health services, Sleep, Volume 41, Issue 8, 1

August 2018

CBT in Insomnia & Depression

• Results: • CBT-I and CBT-I+ both showed significantly greater reduction in insomnia and

depression severity compared to PCG control • Large effects sizes, high retention and strong remission rates • Results were maintained at follow-up

• Conclusion: CBT-I, and CBTI+ were both effective in reducing insomnia and depression severity in older adults.

Paul Sadler, Suzanne McLaren, Britt Klein, Jack Harvey, Megan Jenkins; Cognitive behavior therapy for older adults with insomnia and depression: a randomized controlled trial in community mental health services, Sleep, Volume 41, Issue 8, 1 August 2018

Music and Sleep Quality in Primary Insomnia-a Meta-analysis

• Purpose: To determine if music improves sleep quality in adults with primary insomnia

• Method: Network meta-analysis • Databases: PubMed, Embase, Cochrane Library,

China National Knowledge Infrastructure Library • Publications from 1998 to May 2017 • Music interventions for primary insomnia • Outcome was sleep quality (PSQI and overall sleep quality) • Secondary outcomes were sleep latency and sleep efficiency

Feng F, Zhang Y, Hou J, Cai J, Jiang Q, Li X, Zhao Q, Li BA. Can music improve sleep quality in adults with primary insomnia? A systematic review

and network meta-analysis. Int J Nurs Stud. 2018 Jan;77:189-196.

Music and Sleep Quality • Results:

• 20 trials, N=1339 insomnia patients; 684 music intervention groups; 655 no music control • 12 treatment groups: acupuncture, music & language induction, listening to music, music and

acupuncture, music assisted relaxation, music assisted relaxation and stimulus control, music with exercise, stimulus control, usual care (health info and hypnosis), western medicine, placebo music

• All interventions significantly better than usual care for improving PSQI • Only music-associated relaxation was significantly better than usual care for improving

overall sleep quality • Only music-assisted relaxation and listening to music had significant advantages for sleep

latency • Listening to music top rated intervention by patients and ranked best for improving SE

• Conclusions: • Music intervention offers clear advantages for adults with primary insomnia. • Listening to music and music-associated relaxation are probably the best options to consider

in the application of music intervention.

Feng F, Zhang Y, Hou J, Cai J, Jiang Q, Li X, Zhao Q, Li BA. Can music improve sleep quality in adults with primary insomnia? A systematic review and network meta-analysis. Int J Nurs Stud. 2018 Jan;77:189-196.

Blocking Nocturnal Blue Light for Insomnia • Purpose: To determine if wearing amber-tinted blue light-blocking lenses before bed improves

sleep in individuals with insomnia

• Method: • Participants: n=14 (8 F; age 46.6 + 11.5) with insomnia >3 months (ISQ)

• Exclusion: OSA, sleep disorders, >5 on STOP-Bang, shift work, smoker, beta blockers, psychiatric disorder, antidepressives or anti anxiety meds, pregnant, breastfeeding of caffeine >400mg/day

• Design: • Randomized placebo controlled crossover design • Amber or clear lens glasses worn for 2 hrs before bedtime for 1 week with 4 wk washout • Told to put on glasses during night awakening if light turned on, electronic device used or got out of bed

• Measures: • Pittsburgh Insomnia Rating Scale and Quality of Life, Distress and Sleep Parameter subscales completed at 1800

after 7-d of intervention • Post sleep questionnaire completed every day (SOL, TST, WASO, overall evaluation of sleep and soundness) • Log of when used the glasses • Actigraphy

Shechter, A, Kim EW, St-Onge, MP, Westwood, AJ. Blocking nocturnal blue light or insomnia: A randomized controlled trial. J Psychi Res, Jan 2018, 96, 196-202

Blocking Nocturnal Blue Light • Results: Compared to clear lenses, amber lenses significantly

improved: • PIRS total score (88 vs 72)

• QOL (18 vs 14)

• Distress (56 vs 46)and Sleep Parameter subscales (13 vs 11)

• Overall quality & soundness of sleep significantly higher (3.3 vs 4; 3.3 vs 4.3)

• Reported wake up time significantly delayed (6h:47m vs 7h:15m)

• Subjective TST increased (347 vs 399 min)

• No difference in actigraphy sleep parameters between groups

Conclusion: Amber lenses are a safe, affordable and an easily implemented therapeutic intervention for insomnia symptoms.

Understanding Insomnia

Explanations Given for Going to Bed Late

• Participants: N=17 (7F) ages 20-62 who were frequent bedtime procrastinators and without a Dx of sleep disorders or shift work

• Method: in-depth structured interview and thematic analysis

• Results: Three emerging themes • Deliberate procrastination- willful delay because they deserved time for themselves

• Mindless procrastination- lost track of time

• Strategy delay- need delay in order to fall asleep quickly

• Conclusion: Different causes can direct interventions • Sanne Nauts, Bart A. Kamphorst, Wim Stut, Denise T. D. De Ridder & Joel H. Anderson (2018) The Explanations People Give for Going to Bed Late: A

Qualitative Study of the Varieties of Bedtime Procrastination, Behavioral Sleep Medicine

Insomnia as a Path to Alcoholism • Objective: To assess the risks of Alcohol as a sleep aid by evaluating tolerance

development to sedative–hypnotic effects and subsequent dose escalation

• Method: • Participants: volunteers 21-55 (50% F) with insomnia (DSM-4: SE <85% on

PSG, AHI, PLM <10), good medical and psychiatric health, with no hx of alcoholism or drug abuse

• Design: 2 experiments using 1:4 ratio of vodka:tonic water; first night adapt • Exp #1 n=24; doses 0, 0.3 or 0.6 g/kg ethanol (n=8/dose) before 8hr-PSG on 6 nights • Exp #2 n=12, after 6 nights of ethanol 0.45 g/kg (n=6) vs placebo (n=6) choice of ethanol

or placebo for 7 nights (placebo was tonic water with 5 drops vodka on top) • Measures: PSG parameters, # nights ethanol chosen by each ethanol group

• Timothy Roehrs, Thomas Roth; Insomnia as a path to alcoholism: tolerance development and dose escalation, Sleep, Volume 41, Issue 8, 1 August 2018,

Insomnia a Path to Alcoholism

• Exp 1 - comparison between night 2 (N2) of alcohol vs night 6 (N6) • 0.6g/kg dose had higher SE and TST on N2 compared to 0 and 0.3g/kg (p<.05) • 0.6/kg dose had lower SE and TST on N6 compared to N2 (p<.05) • No difference between 0, 0.3, 0.6 on N6 for SE, TST • Stage 3 significantly decreased on night 6 from night 2

• Exp 2 - after 7 nights of alcohol (4.5g/kg) or placebo and opposite drink on N8, Ss had 7 choice nights to choose with max 3 refills allowed started with 0.2g/kg alcohol

• ethanol pretreated group chose ethanol 54% of nights vs 37% for placebo group • ethanol pretreated group had significantly more total ethanol refills over 7 nights

than placebo pretreated group (7+1.9 vs 3.5+2) with 3 refills max allowed • Ethanol group self administered averaged 1 refill (0.4 g/kg) vs placebo with 0 refills

on half of the nights • No difference in refills across the 7 nights between groups

Insomnia and Alcohol

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Timothy Roehrs, Thomas Roth; Insomnia as a path to alcoholism: tolerance development and dose escalation, Sleep, Volume 41, Issue 8, 1 August 2018

Insomnia a Pathway to Alcohol

Results:

• 0.6 g/kg ethanol increased TSE and stage 3 on night 2, effects lost by night 6

• After 6 nights of pretreatment, choice nights had more self-administered ethanol refills than placebo

Conclusion:

• Alcohol is a risk as a sleep aid among individuals with insomnia.

• Initially a moderate dose of ethanol improved NPSG sleep but was lost by night 6.

• Tolerance was associated with enhanced self-administration

Timothy Roehrs, Thomas Roth; Insomnia as a path to alcoholism: tolerance development and dose escalation, Sleep, Volume 41, Issue 8, 1 August 2018

Insomnia Patients With Objective Short Sleep Duration Have a Blunted Response to CBT for Insomnia1

• Purpose: Do insomnia patients with <6 hrs objective sleep time respond differently to CBT-I than insomnia patients with >6 hrs objective sleep time (normal sleep time)

• Participants: n=60, ages 40-75 (51% F)without co-morbid mental health or sleep interfering conditions. Complaint of SMI, DX insomnia based on DSM-4, WASO>60 on diary, insomnia >6 months with onset after 10 years old, reporting >1 poor sleep hygiene practice. Exclusions: pregnant, medical condition affecting sleep, major psychiatric disorder, <27 on MMSE, substance abuse, using anxiolytics or antidepressants, AHI >15 or PLMSA>15, other sleep disorders, PSG TST >2 hours different from subjective estimate.

• Design: participants randomly assigned waitlist or 1,2,4 or 8 treatment sessions. Initially blind to number of sessions until after first session to encourage maximum use of first session. Baseline actigraphy and some actigraphy during treatment, first session 45-60 min and subsequent session 15-30 min)

• Measures: baseline PSG, actigraphy, sleep diary, ISQ, Therapy evaluation questionnaire all done for 2 weeks baseline, through 8 week treatment period and for 2 weeks at 3 and 6 month follow-up

Christina J. Bathgate PhD1, Jack D. Edinger PhD1,2, Andrew D. Krystal MD2. Insomnia Patients with Objective Short Sleep Duration have a blunted response to CBT for insomnia. SLEEP, Vol. 40, (1), 2017.

Insomnia Patients with Short Sleep Duration have Blunted Response to CBT-I

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Christina J. Bathgate PhD1, Jack D. Edinger PhD1,2, Andrew D. Krystal MD2. Insomnia Patients with Objective Short Sleep Duration

have a blunted response to CBT for insomnia. SLEEP, Vol. 40, (1), 2017.

Total Sleep Time Measured by Actigraphy and Diaries in Each Group

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Conclusions

• Varying insomnia phenotypes show differential response to CBT

• Insomnia patients with objective short sleep time <6 show a truncated response to CBT-I compared to those with >6 hours TST

• Suggested that insomnia patients with short objective sleep time may benefit more from CBT combined with pharmacological treatment

• Christina J. Bathgate PhD1, Jack D. Edinger PhD1,2, Andrew D. Krystal MD2. Insomnia Patients with Objective Short Sleep Duration

have a blunted response to CBT for insomnia. SLEEP, Vol. 40, (1), 2017

PTSD is Associated with Reduced Parasympathetic Activity in NREM

• Purpose: Examine high frequency HR variability (HF-HRV)in sleep in PTSD

• Methods: • Participants: 62 veterans, with PTSD (n=29, age 33+7) and without PTSD

(n=33, age31+8)) • Measures:

• self-reported sleep quality • insomnia severity index • Self-reported disruptive nocturnal behaviors • in-lab PSG

Christi S Ulmer, Martica H Hall, Paul A Dennis, Jean C Beckham, Anne Germain, Posttraumatic Stress Disorder Diagnosis is Associated with Reduced Parasympathetic Activity during Sleep in United States Veterans and Military Service Members of the Iraq and Afghanistan Wars, Sleep 2018, August 29

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Results: • PTSD vets had significantly lower HF HRV in NREM compared to those

without PTSD. This was significant in 1st and 4th NREM cycles. • Groups did not differ in REM

Conclusion: There is blunted parasympathetic modulation during NREM in young veterans with PTSD Christi S Ulmer, Martica H Hall, Paul A Dennis, Jean C Beckham, Anne Germain, Posttraumatic Stress Disorder Diagnosis is Associated with Reduced Parasympathetic Activity during Sleep in United States Veterans and Military Service Members of the Iraq and Afghanistan Wars, Sleep 2018, August 29

Influence of Exercise Time of Day on Salivary

Melatonin Responses

• Purpose: Evaluate the influence of exercise time of day on melatonin

• Methods: • 12 regularly exercising males (age 20.8+0.6) • randomized crossover design • All completed 3 protocols separated by > 5 days:

• morning exercise (AMEX; 09:00) • afternoon exercise (PMEX, 1400) • no exercise

• Exercise was 30 min of running at 75% of VO2max • Saliva collected at 20:00h, 22:00h and 03:00 h following each session

Carlson LA, Pobocik KM, Lawrence MA, Brazeau DA, Koch AJ. Influence of Exercise Time of Day on Salivary Melatonin Responses Int J Sports Physiol Perform. 2018 Aug 30:1-13

https://www.ncbi.nlm.nih.gov/pubmed/30160559

Influence of time of Exercise on Melatonin

• Results: Significant time and condition effects • s-melatonin significantly increased 03:00 compared to 20h and 22h for all

conditions.

• s-melatonin at 22:00 significantly higher after AMEX (16.5 ± 7.5 pg·mL-1) compared to PMEX (13.7 ± 6.1 pg·mL-1) . Neither differed from control

• Conclusion: Exercising in the afternoon may blunt melatonin secretion as compared to morning exercise. If sleep is an issue morning exercise may be preferable to afternoon exercise.

Reproducibility of the Epworth Sleepiness Scale

• Objective- to measure reproducibility of ESS in suspected OSA pts 1

• Method- retrospective comparison of ESS score at referral and after 1st sleep clinic visit

• Demo: 154 pts (68% M), mean age 51 +13, AHI = 43 + 40

Campbell AJ, Neill AM, Scott DA. Clinical reproducibility of the Epworth Sleepiness Scale for patients with suspected sleep apnea. J Clin Sleep Med. 2018;14(5):791-5.

Changes in ESS Score

• Results – • No statistically significant difference between mean ESS score at referral and first

visit (13.7 ± 4.9 vs 13.5 ± 4.6) (P = .61) • Ave ESS change was -0.2 + 3.9 • 7% dropped from above ESS=10 and 7.8% increased over ESS=10 • 8% had an ESS change of 7 or more • 21% had an ESS change of 5 points or more • 46% had an ESS change of 3 points or more

• Conclusion: ESS is variable and should not be used as the sole tool to prioritize patients for OSA assessment

Campbell AJ, Neill AM, Scott DA. Clinical reproducibility of the Epworth Sleepiness Scale for patients with suspected sleep apnea. J Clin Sleep Med. 2018;14(5):791-5.

8%

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46%

7ormore

5ormore

3ormore

Requiem for Clinical Use of the ESS

Commentary on the ESS reproducibility study

• ESS performed worst with 39% sensitivity compared to STOP BANG at 87% for identifying OSA risk

• Need to abandon this subjective measure in evaluation of OSA

1Omobomi O, Quan SF. A requiem for the clinical use of the Epworth Sleepiness Scale. J Clin Sleep Med. 2018;14(5):711–712.

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Updates in Behavioral Sleep Medicine 2018 relaxation, and rescripting therapy; hypnosis; lucid dreaming therapy; progressive deep muscle relaxation; sleep dynamic therapy; self-exposure