Refractory Insomnia and Sleep-Disordered Breathing: A Pilot Study

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

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