Refractory Insomnia and Sleep-Disordered Breathing: A Pilot Study

Barry Krakow; Dominic Melendrez; Samuel A. Lee; Teddy D. Warner; Jimmy O. Clark; David Sklar

doi:10.1055/s-2004-822850

Sleep Breath 2004; 8(1): 15-29
DOI: 10.1055/s-2004-822850

ORIGINAL ARTICLE

Refractory Insomnia and Sleep-Disordered Breathing: A Pilot Study

Barry Krakow¹ ^, ² ^, ³ ^, ⁴ , Dominic Melendrez¹ , Samuel A. Lee¹ , Teddy D. Warner² ^, ³ ^, ⁵ , Jimmy O. Clark¹ , David Sklar² ^, ⁴

¹Sleep and Human Health Institute, Albuquerque, New Mexico
²University of New Mexico Health Sciences Center, Albuquerque, New Mexico
³Department of Psychiatry, University of New Mexico School of Medicine, Albuquerque, New Mexico
⁴Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
⁵Institute of Ethics, University of New Mexico Health Sciences Center, Albuquerque, New Mexico

Abstract

Objective: To assess an uncontrolled, open-label trial of sleep-disordered breathing (SDB) treatment on two different samples of chronic insomnia patients. Method: In Study 1 (Retrospective), data from one diagnostic and one continuous positive airway pressure (CPAP) titration polysomnogram were compiled from 19 chronic insomnia patients with SDB. Objective polysomnogram indicators of sleep and arousal activity and self-reported sleep quality were measured. In Study 2 (Prospective), clinical outcomes were assessed after sequential cognitive-behavioral therapy (CBT) and SDB therapy (CPAP, oral appliances, or bilateral turbinectomy) were provided to 17 chronic insomnia patients with SDB. Repeat measures included the Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire, Pittsburgh Sleep Quality Index, and self-reported insomnia indices and CPAP use. Results: In Study 1, seven objective measures of sleep and arousal demonstrated or approached significant improvement during one night of CPAP titration. Sixteen of 19 patients reported improvement in sleep quality. In Study 2, Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire, and Pittsburgh Sleep Quality Index improved markedly with CBT followed by SDB treatment and achieved an average outcome equivalent to curative status. Improvements were large for each treatment phase; however, of 17 patients, only 8 attained a nonclinical level of insomnia after CBT compared with 15 patients after SDB therapy was added. Self-reported insomnia indices also improved markedly, and self-reported SDB therapy compliance was high. Conclusions: In one small sample of chronic insomnia patients with SDB, objective measures of insomnia, arousal, and sleep improved during one night of CPAP titration. In a second small sample, validated measures of insomnia, sleep quality, and sleep impairment demonstrated clinical cures or near-cures after combined CBT and SDB therapies. These pilot results suggest a potential value in researching the pathophysiological relationships between SDB and chronic insomnia, which may be particularly relevant to patients with refractory insomnia.

KEYWORDS

Insomnia - sleep-disordered breathing - sleep fragmentation - obstructive sleep apnea - upper airway resistance syndrome - polysomnography - continuous positive airway pressure - oral appliance therapy

Full Text

References

REFERENCES

1 Bonnet M H, Arand D L. Diagnosis and treatment of insomnia. Respir Care Clin N Am. 1999; 5 333-348
2 American Psychiatric Association .Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed, text revision. Washington, DC; American Psychiatric Association 2000: 597-661
3 Nofzinger E A, Buysse D J, Reynolds III C F, Kupfer D J. Sleep disorders related to another mental disorder (nonsubstance/primary): a DSM-IV literature review. J Clin Psychiatry. 1993; 54 244-255
4 Nowell P D, Buysse D J, Reynolds III C F et al.. Clinical factors contributing to the differential diagnosis of primary insomnia and insomnia related to mental disorders. Am J Psychiatry. 1997; 154 1412-1416
5 Buysse D J, Reynolds III C F, Hauri P J et al.. Diagnostic concordance for DSM-IV sleep disorders: a report from the APA/NIMH DSM-IV field trial. Am J Psychiatry. 1994; 151 1351-1360
6 Hatoum H T, Kong S X, Kania C M, Wong J M, Mendelson W B. Insomnia, health-related quality of life and healthcare resource consumption. A study of managed-care organization enrollees. Pharmacoeconomics. 1998; 14 629-637
7 Kim K, Uchiyama M, Liu X et al.. Somatic and psychological complaints and their correlates with insomnia in the Japanese general population. Psychosom Med. 2001; 63 441-446
8 Leger D, Scheuermaier K, Philip P et al.. SF-36: evaluation of quality of life in severe and mild insomniacs compared with good sleepers. Psychosom Med. 2001; 63 49-55
9 Katz D A, McHorney C A. The relationship between insomnia and health-related quality of life in patients with chronic illness. J Fam Pract. 2002; 51 229-235
10 Lamarche C H, Ogilvie R D. Electrophysiological changes during the sleep onset period of psychophysiological insomniacs, psychiatric insomniacs, and normal sleepers. Sleep. 1997; 20 724-733
11 Bonnet M H, Arand D L. Physiological activation in patients with sleep state misperception. Psychosom Med. 1997; 59 533-540
12 Merica H, Blois R, Gaillard J M. Spectral characteristics of sleep EEG in chronic insomnia. Eur J Neurosci. 1998; 10 1826-1834
13 Bonnet M H, Arand D L. Heart rate variability in insomniacs and matched normal sleepers. Psychosom Med. 1998; 60 610-615
14 Morin C M. The nature of insomnia and the need to refine our diagnostic criteria. Psychosom Med. 2000; 62 483-485
15 Rosa R R, Bonnet M H. Reported chronic insomnia is independent of poor sleep as measured by electroencephalography. Psychosom Med. 2000; 62 474-482
16 Hall M, Buysse D J, Nowell P D et al.. Symptoms of stress and depression as correlates of sleep in primary insomnia. Psychosom Med. 2000; 62 227-230
17 Richardson G S, Roth T. Future directions in the management of insomnia. J Clin Psychiatry. 2001; 62(suppl) 39-45
18 Perlis M L, Smith M T, Andrews P J, Orff H, Giles D E. Beta/gamma EEG activity in patients with primary and secondary insomnia and good sleeper controls. Sleep. 2001; 24 110-117
19 Perlis M L, Kehr E L, Smith M T et al.. Temporal and stagewise distribution of high frequency EEG activity in patients with primary and secondary insomnia and in good sleeper controls. J Sleep Res. 2001; 10 93-104
20 Vgontzas A N, Bixler E O, Wittman A M et al.. Middle-aged men show higher sensitivity of sleep to the arousing effects of corticotropin-releasing hormone than young men: clinical implications. J Clin Endocrinol Metab. 2001; 86 1489-1495
21 Vgontzas A N, Bixler E O, Lin H M et al.. Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal axis: clinical implications. J Clin Endocrinol Metab. 2001; 86 3787-3794
22 Shaver J L, Johnston S K, Lentz M J, Landis C A. Stress exposure, psychological distress, and physiological stress activation in midlife women with insomnia. Psychosom Med. 2002; 64 793-802
23 Morin C. Insomnia: Psychological Assessment and Management. New York, NY; Guilford Press 1993: 9-15
24 Edinger J D, Wohlgemuth W K, Radtke R A, Marsh G R, Quillian R E. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. JAMA. 2001; 285 1856-1864
25 Thase M E. Antidepressant treatment of the depressed patient with insomnia [review]. J Clin Psychiatry. 1999; 60(suppl 17) 28-31 , discussion 46-48
26 Murtagh D R, Greenwood K M. Identifying effective psychological treatments for insomnia: a meta-analysis. J Consult Clin Psychol. 1995; 63 79-89
27 Chesson Jr A L, Anderson W M, Littner M et al.. Practice parameters for the nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 1999; 22 1128-1133
28 Morin C M, Hauri P J, Espie C A et al.. Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine review. Sleep. 1999; 22 1134-1156
29 Lichstein K L, Wilson N M, Johnson C T. Psychological treatment of secondary insomnia. Psychol Aging. 2000; 15 232-240
30 Lichstein K L, Riedel B W, Wilson N M, Lester K W, Aguillard R N. Relaxation and sleep compression for late-life insomnia: a placebo-controlled trial. J Consult Clin Psychol. 2001; 69 227-239
31 Espie C A, Inglis S J, Harvey L. Predicting clinically significant response to cognitive behavior therapy for chronic insomnia in general medical practice: analysis of outcome data at 12 months posttreatment. J Consult Clin Psychol. 2001; 69 58-66
32 Harvey L, Inglis S J, Espie C A. Insomniacs' reported use of CBT components and relationship to long-term clinical outcome. Behav Res Ther. 2002; 40 75-83
33 American Academy of Sleep Medicine .The international classification of sleep disorders. Lawrence, Kansas; Allen Press Inc 1997: 52-58
34 Krakow B, Germain A, Tandberg D et al.. Sleep breathing and sleep movement disorders masquerading as insomnia in sexual assault survivors with PTSD. Compr Psychiatry. 2000; 41 49-56
35 Krakow B, Artar A, Warner T D et al.. Sleep disorder, depression, and suicidality in female sexual assault survivors. Crisis. 2000; 21 163-170
36 Krakow B, Germain A, Warner T D et al.. The relationship of sleep quality and posttraumatic stress to potential sleep disorders in sexual assault survivors with nightmares, insomnia and PTSD. J Trauma Stress. 2001; 14 647-665
37 Krakow B, Melendrez D, Santana E et al.. Prevalence and timing of sleep disturbance in Cerro Grande Firestorm victims. Sleep. 2001; 24(suppl) A394
38 Krakow B, Hollifield M, Johnston L et al.. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA. 2001; 286 537-545
39 Krakow B, Johnston L, Melendrez D et al.. An open-label trial of evidence-based cognitive behavioral therapy for nightmares and insomnia in crime victims with PTSD. Am J Psychiatry. 2001; 158 2043-2047
40 Krakow B, Melendrez D C, Johnston L G et al.. Sleep dynamic therapy for Cerro Grande Fire evacuees with posttraumatic stress symptoms: a preliminary report. J Clin Psychiatry. 2002; 63 673-684
41 Krakow B, Lowry C, Germain A et al.. A retrospective study on improvements in nightmares and posttraumatic stress disorder following treatment for co-morbid sleep-disordered breathing. J Psychosom Res. 2000; 49 291-298
42 Melendrez D, Krakow B, Johnston L, Sisley B, Warner T D. A prospective study on the treatment of “complex insomnia”-insomnia plus sleep-disordered breathing-in a small series of crime victims with PTSD. Sleep. 2001; 24(suppl) A120
43 Krakow B, Melendrez D, Johnston L et al.. Sleep-disordered breathing, psychiatric distress, and quality of life impairment in sexual assault survivors. J Nerv Ment Dis. 2002; 190 442-452
44 American Academy of Sleep Medicine . Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sleep. 1999; 22 667-689
45 Krakow B, Melendrez D, Ferreira E et al.. Prevalence of insomnia symptoms in sleep-disordered breathing patients. Chest. 2001; 120 1923-1929
46 Krakow B, Melendrez D, Warner T D et al.. To breathe, perchance to sleep: sleep-disordered breathing and chronic insomnia among trauma survivors. Sleep Breath. 2002; 6 189-202
47 Chung K F, Krakow B, Melendrez D, Warner T D, Sisley B. Relationships between insomnia and sleep-disordered breathing [letter]. Chest. 2003; 123:310 313
48 Namen A M, Dunagan D P, Fleischer A et al.. Increased physician-reported sleep apnea: the National Ambulatory Medical Care Survey. Chest. 2002; 121 1741-1747
49 Ohayon M M, Roth T. What are the contributing factors for insomnia in the general population?. J Psychosom Res. 2001; 51 745-755
50 Guilleminault C. Clinical features and evaluation of obstructive sleep apnea. In: Kryger MH, Roth T, Dement WC Principles and Practice of Sleep Medicine. 2nd ed. London; WB Saunders Co 1994: 552-558
51 Krakow B, Melendrez D, Pedersen B et al.. Complex insomnia: insomnia and sleep-disordered breathing in a consecutive series of crime victims with nightmares and PTSD. Biol Psychiatry. 2001; 49 948-953
52 Hosselet J J, Norman R G, Ayappa I. Detection of flow limitation with a nasal cannula/pressure transducer system. Am J Respir Crit Care Med. 1998; 157 1461-1467
53 Montserrat J M, Farre R, Ballester E et al.. Evaluation of nasal prongs for estimating nasal flow. Am J Respir Crit Care Med. 1997; 155 211-215
54 Guilleminault C, Stoohs R, Duncan S. Snoring (I). Daytime sleepiness in regular heavy snorers. Chest. 1991; 99 40-48
55 ResMed .AutoSet Portable 2 Plus Overview and Interpretation Guide. San Diego, CA; Res Med 1998
56 Gugger M. Comparison of ResMed AutoSet (version 3.03) with polysomnography in the diagnosis of the sleep apnoea/hypopnoea syndrome. Eur Respir J. 1997; 10 587-591
57 Exar E N, Collop N A. The upper airway resistance syndrome. Chest. 1999; 115 1127-1139
58 Ayappa I, Norman R G, Krieger A C et al.. Non-invasive detection of respiratory effort-related arousals (RERAs) by a nasal cannula/pressure transducer system. Sleep. 2000; 23 763-771
59 Liam C K. A portal recording system for the assessment of patients with sleep apnoea syndrome. Med J Malaysia. 1996; 51 82-88
60 Guilleminault C, Palombini L, Poyares D. Chronic insomnia, postmenopausal women, and sleep-disordered breathing. Part 1. Frequency of sleep-disordered breathing in a cohort. J Psychosom Res. 2002; 53 611-615
61 Guilleminault C, Palombini L, Poyares D, Chowdhuri S. Chronic insomnia, postmenopausal women and sleep-disordered breathing. Part 2. Comparison of nondrug treatment trials in normal breathing and UARS postmenopausal women complaining of chronic insomnia. J Psychosom Res. 2002; 53 617-623
62 Grunstein R, Sullivan C. Continuous positive airway pressure for sleep breathing disorders. In: Kryger MH, Roth T, Dement WC Principles and Practice of Sleep Medicine. 3rd ed. Philadelphia; WB Saunders Co 2000: 894-912
63 McGregor P, Thorpy M J, Schmidt-Nowara W W, Ledereich P S, Snyder M. T-sleep: an improved method for scoring breathing-disordered sleep. Sleep. 1992; 15 359-363
64 Bastien C H, Vallieres A, Morin C M. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001; 2 297-307
65 Weaver T E, Laizner A M, Evans L K et al.. An instrument to measure functional status outcomes for disorders of excessive sleepiness. Sleep. 1997; 20 835-843
66 Buysse D, Reynolds III C, Monk T, Berman S R, Kupfer D J. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989; 28 193-213
67 Morin C M, Blais F, Savard J. Are changes in beliefs and attitudes about sleep related to sleep improvements in the treatment of insomnia?. Behav Res Ther. 2002; 40 741-752
68 Morin C M, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA. 1999; 281 991-999
69 Saletu B, Klosch G, Gruber G et al.. First-night-effects on generalized anxiety disorder (GAD)-based insomnia: laboratory versus home sleep recordings. Sleep. 1996; 19 691-697

Barry KrakowM.D.

Sleep and Human Health Institute

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