Sleep Disorders In Adults Research Articles

Recognize and address ADHD‐related sleep disorders in adults

Sleep disorders related to attention deficit hyperactivity disorder are common. Many doctors and others believed these two conditions were unrelated, but recent evidence shows otherwise. Certain sleep problems are now thought to be specific to ADHD, requiring careful differential diagnosis, targeted medical treatments and effective strategies.

Adult Night Terrors Since Childhood: A Case Report

Confusion exists among medical professionals in differentiating a night terror episode (NTE) from a nightmare and other sleep disorders in adults. NTEs that persist into adulthood are considered rare in the literature. Devastating injuries occur during NTEs reveal the need for further examination of the physical, mental, and emotional impacts on the patient in order to create lasting curative treatment options. Often, adults who are experiencing NTE do not seek medical help until they hurt themselves, someone else, or until they can no longer cope with the overall effects of disrupted sleep. Much of the literature regarding NTEs is focused on children who, while having a higher prevalence of NTEs, ultimately outgrow the problem without medical intervention. A female with over 40 years of NTE history is studied and the resulting impact on her life is explored. Precipitating factors such as stress and aberrant noise are identified. Various forms of treatment using medications and relaxation techniques are assessed. Misdiagnosis and misunderstanding by medical personnel is also noted in her case. A concise understanding of NTEs throughout all medical specialties is necessary in order to differentiate between the various forms of parasomnias and sleep disorders and to offer appropriate treatment options. Primary care physicians sleep disorder specialists, pain management specialists, orthopaedic and neurology specialists, and psychiatrists could easily encounter such a patient. The importance of recognizing and immediately treating NTEs in adults is vital to the safety and psychology of the possible patients and others affected.

제 1형 당뇨병 소아 청소년의 하지불안증후군

목 적 : 제 1형 당뇨병을 진단 받은 소아 청소년 환자들을 대상으로 RLS를 평가하고 RLS를 동반하는 환자군과 RLS를 동반하지 않은 환자군 간의 임상적 변인과 수면의 특성을 비교하고자 하였다. 방 법 : 소아 청소년과에서 제 1형 당뇨병으로 진단 받은 7세 이상 18세 이하의 소아 청소년 55명을 대상으로 면담, 설문조사, 임상학적 검사를 시행하였다. RLS 진단은 IRLSSG 진단기준을 따랐으며 설문은 Epworth sleepiness scale (ESS), International restless legs syndrome rating scale (IRLSRS)를 이용하였다. 결 과 : 55명의 대상자 중 RLS 빈도는 13명으로 23.6%였다. RLS 관련 변인으로 BMI, Hb, Iron, ferritin, TIBC, creatinine, GFR에서 두 군간에 유의한 차이는 없었다. RLS 환자 13명 중 RLS 가족력을 가진 환자는 7명으로, RLS가 없는 환자의 경우와 현저한 차이를 보였다. 수면의 특성을 조사한 결과 RLS를 동반한 환자군이 RLS를 동반하지 않은 군에 비해 ESS, IRLSRS 결과가 유의하게 높았다. 결 론 : 제 1형 당뇨병을 진단 받은 소아 청소년은 RLS가 흔히 동반되었다. 임상적으로 당뇨 소아 청소년의 RLS 동반여부와 수면의 질을 평가하여 치료하는 것이 필요하겠으며 향후 보다 많은 환자를 대상으로 보다 객관적인 방법을 이용한 연구가 진행되어야 할 것이다. Objectives: Restless legs syndrome (RLS) is a common sleep disorder in adults with diabetes. This study investigated the frequency of RLS and clinical correlations in children and adolescents with type 1 diabetes. Methods: This study included 55 consecutive patients (21 males, age <TEX>$12.6{\pm}3.4years$</TEX>) with type I diabetes that were regularly treated at the Department of Pediatric Endocrinology. RLS was diagnosed by intensive interviews which also included the Epworth Sleepiness Scale (ESS) and International RLS Rating Scale (IRLSRS). Patients also received neurological examinations and laboratory tests for diabetes, iron metabolism and renal function. Results: Thirteen patients (23.6%, 6 males) were compatible for the diagnostic criteria of RLS. None of the RLS patients showed abnormal findings in neurological evaluations and 7 patients had familial history of RLS. Demographic and laboratory findings were not different between the patients with or without RLS. The RLS group showed significantly increased ESS and IRLSRS scores. Conclusion: RLS was prevalent in children and adolescents with type 1 diabetes. The association between RLS and diabetes-related laboratory findings requires further investigation.

A Profile of Sleep Architecture and Sleep Disorders in Adults with Chronic Traumatic Brain Injury

The primary acceleration-deceleration mechanism of traumatic brain injury (TBI) leaves the brain structures that regulate sleep and wakefulness vulnerable to pathological changes, and there are external secondary factors experienced post-injury that can contribute to the development of difficulties initiating or maintaining sleep, early morning awakening, and/or dissatisfaction with sleep. Patients with TBI are at risk for developing chronic sleep-wake disturbances, and complaints of insomnia and hypersomnia are commonly reported. The objective of this study was to examine sleep architecture and explore the presence and types of sleep disorders in adults with chronic TBI. Method: Participants (N=13, mean time post injury 4.5 years) underwent polysomnography and the Maintenance of Wakefulness Test. Polysomnographic findings were compared to age and sex normative data. Sleep disorders were diagnosed according to the criteria of the International Classification of Sleep Disorders, 2nd edition. Results: Compared to normative data, 92% had abnormal sleep architecture with increased N1 (p=.002), reductions in REM sleep (p=0.017) and total sleep time, and poor sleep efficiency. All were diagnosed with a treatable sleep disorder according to the ICSD-2. Conclusion: These exploratory findings add to a growing body of evidence that TBI is associated with a high prevalence of sleep disorders which underlie alterations in sleep architecture including increased arousability, greater amounts of transitional sleep stages, and altered REM latency and duration.These results highlight the importance of regular screening and assessment of sleep-wake disorders early in the rehabilitation stage for this population in order to prevent the development of chronic sleep disorders.

Sleep disorders in adults with epilepsy: past, present, and future directions.

To summarize recent studies on the complex relationships between sleep disorders, sleep, and epilepsy. Insomnia in adults with epilepsy (AWE) warrants consideration of depression, anxiety, and suicidal ideation. Daytime sleepiness in AWE is more often due to undiagnosed sleep disorders. Sleep deprivation is an important provoker of seizures in juvenile myoclonic epilepsy. Abnormalities in frontal lobe executive function with difficulties making advantageous decisions may explain failure of juvenile myoclonic epilepsy patients to adhere to treatment recommendations and regulate their sleep habits. Sleep architecture in AWE is more likely to be abnormal if seizures are poorly controlled or occur during sleep. Obstructive sleep apnea is much more common in AWE who are man, older, heavier, or whose seizures are poorly controlled. Chronobiology and chronopharmacology of epilepsy is an emerging field worthy of future research and clinical applications. Identifying and treating unrecognized sleep disorders and understanding the impact of circadian rhythms on epilepsy can improve quality of life and seizure control in AWE.

Editorial (Thematic Issue: Sleep and Psychiatry)

Disturbances of the sleep-wake pattern constitute one of the major complaints of patients with a wide range of psychiatric conditions, including major depression disorder, anxiety disorders, bipolar disorders, schizophrenia, borderline personality disorder, eating disorders, and alcohol abuse. Recent advances have cast light on the mecanisms underlying modifications in sleep in psychiatric disorders, offering new approaches in management and opening new avenues of research. Isnomnia and psychiatric disorders, especially depression, are intimately linked. Insomnia, defined as a difficulty in initiating and/or in maintaining sleep leading to daytime repercussions, is not simply a symptom of depression but an independent diagnostic entity, and is known to be an independent risk factor for both depression itself and the development of a new depression episode or relapse. To date, the psychological and neurobiological mechanisms underlying the relationships between insomnia and affective disorders are not yet fully understood. The review by Chiara Baglioni et al. examines the latest findings from several fields of research, with particular attention to alterations of the arousal system leading to hyperarousal and to the possible biological mechanisms involved in the link between sleep alteration, insomnia, regulation of emotion, and mood symptoms. Links between depression sleep and circadian rhythms have long been suspected due to the existence of seasonal depression, where the onset of low mood correlates with a reduction in day length. Seasonal affective disorder (SA) is primarily a circadian rhythm disorder. Alfred Lewy discusses the theory of misalignement between the circadian rhythm of melatonin secretion and the midpoint of the sleep bout, and emphasise the importance or careful timing of treatment administration (bright light or melatonin). Timing of treatment administration requiring detailed information on patients’ phase state and the role of new accessible tools such as dim light melatonine onset are evaluated as are different treatment modalities. The importance of biological rhythms in SA disorder has led to an interest in the role of circadian rhythms in the development of depression. The successes of chronobiotic treatments for SA disorder have led to the trialling of psychological and pharmacological treatments targeting circadian rhythms in unipolar major depression (MDD). The review by Sarah Hartley et al. focuses on the research linking circadian rhythms and depression, and on the evidence for effectiveness of chronobiotic treatments such as high intensity light, melatonin or melatonin agonist or behavioural therapy in MDD. The evidence base for novel antidepressants combining 5HT2c antagonist and melatonin agonist action in acute treatment of unipolar MDD and in relapse prevention is reviewed as is their use in clinical management of MDD. Managing bipolar disorder is a challenge for psychiatrists and it has been long known that sleep disorders are a sign of relapse. Carole Boudebesse et al. examine the evidence that sleep and circadian rhythms are disturbed in bipolar patients during both mood episodes and periods of remission. Therapeutic applications of chronobiology in bipolar disorder, such as specific psychosocial interventions, light therapy and physical exercise are described. Finally, psychiatrists are faced with frequent reports of sleep disorders in adults and children with attentiondeficit/ hyperactivity disorder (ADHD) and, conversely, sleep specialists report certain symptoms of ADHD (attention deficits, fidgeting) in patients suffering from primary sleep disorders. Are ADHD symptoms secondary to sleep fragmentation due to sleep disorders such as sleep disordered breathing and periodic legs movements, and treatable with treatment of these specific disorders? Could some ADHD subjects share a common deficit in the sleep/wake regulation systems resulting in sleep fragmentation? The pathophysiological relationship between sleep disorders and ADHD is complex and probably multidirectional. The hot topic from the team of Astrid Claret et al. reviews the latest research and aims to help clinicians in developing a framework for understanding and treating patients suffering from ADHD and sleep disorders.

Sleepiness, Sleep Disorders and Attention-Deficit/Hyperactivity Disorder: Pathophysiological Rationale and Future Perspectives

The links between sleep and attention-deficit hyperactivity disorder (ADHD) have been a topic of ongoing research and clinical interest in children over the last three decades and more recently in adults suffering from ADHD. Clinically, psychiatrists are faced with frequent reports of sleep disorders in adults and children with ADHD and conversely, sleep specialists report certain symptoms of ADHD (attention deficits, urge for fidgeting) in patients suffering from primary sleep disorders. Excessive sleepiness is found in ADHD and sleep disorders such as hypersomnia, sleep breathing disorder (SDB), periodic limb movements in sleep (PLMS) and circadian rhythm disorders. This has encouraged authors to suggest a model of ADHD involving a deficit in alertness. The aim of this article is to clarify the pathophysiological rationale for the relationship between sleep/arousal and attention-deficit/hyperactivity disorder and to explore future perspectives in terms of management, treatment and development of research fields. Keywords: Attention-deficit/ hyperactivity disorder, alerting systems, pathophysiology, sleep, sleep disorders.

Non-contact under-mattress sleep monitoring

Sleep quality and duration are increasingly recognised as being important prognostic parameters in the assessment of an individual’s health. However, reliable non-invasive long-term monitoring of sleep in a non-clinical setting remains a challenging problem. This paper describes the validation of a novel under mattress pressure sensing sleep monitoring modality that can be seamlessly integrated into existing home environments and provides a pervasive and distributed solution for monitoring longterm changes in sleep patterns and sleep disorders in adults. 410 minutes of concomitant Under Mattress Bed Sensor (UMBS) and strain gauge data were analysed from eight healthy adults lying passively. In this analysis, customised respirations rate detection algorithms yielded a mean difference of −0.12 breaths per five minutes and a mean percentage error (MPE) of 0.16% when the sensor was placed beneath the mattress. 1,491 minutes of UMBS and video data were recorded simultaneously from four participants in order to assess the movement detection efficacy of customised UMBS algorithms. These algorithms yielded accuracies, sensitivities and specificities of over 90% when compared to a video-based movement detection gold standard. A reduced data set (267 minutes) of wrist actigraphy, the gold standard ambulatory sleep monitor, was recorded. The UMBS was shown to outperform the movement detection ability of wrist actigraphy and has the added advantage of not requiring active subject participation.

Sleep medicine course

Sleep, why do we need it? What purpose does it serve in humans? Why does it vary between people? How do we diagnose and treat sleep disorders? These questions intrigue me. Unfortunately, there is a dearth of courses in the United Kingdom covering this interesting field of medicine—but one exception is the sleep medicine course in Edinburgh. One of a kind in the UK and possibly Europe, this course has something for everyone who has an interest in or deals with sleep and its disorders and sleep technology. It is aimed at anyone with a medical background who has an interest in sleep medicine or is involved in the diagnosis and management of adult sleep disorders. The course is primarily aimed at sleep physicians, respiratory and general physicians, psychiatrists, psychologists, physiologists, physiotherapists, nurses, anaesthetists, neurologists and other allied health professionals, general practitioners, ear, nose, and throat surgeons, and dentists. I am a higher specialty trainee in psychiatry and have had …

Using actigraphy versus polysomnography in the clinical assessment of chronic insomnia (retrospective analysis of 27 patients)

The current study was conducted in order to investigate whether several different methods of characterizing sleep and insomnia symptoms produce different diagnoses. To this aim, we performed a retrospective study in order to compare the outcome of the assessment obtained using actigraphy with that obtained using polysomnography (PSG) in 27 outpatients complaining of chronic insomnia. Subjects were recruited from a database consisting of patients referred to the sleep centre of the Hôtel-Dieu Hospital (Paris) complaining of chronic insomnia. Patients were divided into different groups with regard to type of insomnia. As far as type of insomnia was concerned, the comparison between actigraphy and PSG showed quite a good contingency coefficient value (C=0.64). Although this was a preliminary and retrospective study, our results seemed to indicate that actigraphy and PSG were able to lead to a similar output particularly with regard to type of insomnia. Beyond PSG, actigraphy might have a clinical utility in assessing sleep disorders in adults complaining of chronic insomnia.

Abordagem da insónia secundária do adulto nos cuidados de saúde primários.

Insomnia is the most common sleep disorder in adults, with secondary insomnia being the most prevalent. This sleep disorder is associated with important medical and social consequences. The General Practitioner (GP) plays a key role in the diagnosis of insomnia, which may affect about 69% of their patients in the PHC (Primary Health Care). Recognize the differential diagnosis of secondary insomnia in adults, evaluate and manage these patients in the PHC, appropriately use the treatments available and meet the criteria for referral. Bibliographic search in MEDLINE databases, and evidence based review databases, using the MeSH terms: Primary Health Care, Sleep Disorders, Insomnia, for articles published since January 2000 until July 2009, in English, Portuguese, French and Spanish. Index de Revistas Médicas Portuguesas and scientific societies dedicated to sleep disorders were searched. Mood and anxiety disorders are the main co-morbidities associated with secondary insomnia, being present in 30% to 50% of patients with insomnia. The medical pathology and substance abuse are present respectively in 10% of patients. It is essential a proper clinical history, with a history of sleep, sleep diary and the partner information. There is evidence that the combination of specific pharmacological treatments (benzodiazepines and the benzodiazepine receptor agonists) with the nonpharmacological (cognitive-behavioral therapy) may be useful in secondary insomnia, as co-adjuvant treatment of the underlying disease. There are several treatment options with their indications and adverse effects. The criteria for referral should be defined according to the availability of human resources. Due to the high prevalence and the serious consequences of secondary insomnia in adults, it must be systematically managed by the GP. It is important to know and to use non-pharmacological therapy in GP consultation, because this therapy was shown to be important in treating this type of insomnia. The GP must know the precise indications for pharmacological treatment and criteria for referral.

Melatonin in treatment of chronic sleep disorders in adults with autism: a retrospective study.

Melatonin may be used to treat sleep disorders in both children and adults with intellectual disability. The evidence for its efficacy, potential adverse effects and drug interactions are reviewed in the context of prescription of melatonin to patients with autism. This study presents the use of melatonin to treat severe circadian sleep-wake disturbances in 6 adults with autism. Melatonin was initiated at a daily dose of 3 mg at nocturnal bedtime. If this proved ineffective, the melatonin dose was titrated over the following 4 weeks at increments of 3 mg/2 weeks up to a maximum of 9 mg, unless it was tolerated. Assessments included Clinical Global Impression-Severity (CGI-S) and CGI-Improvement (CGI-I). Melatonin administered in the evening dramatically improved the sleep-wake pattern in all patients. Melatonin appears to be effective in reducing sleep onset latency and is probably effective in improving nocturnal awakenings and total sleep time in adults with autism. Its effectiveness remained stable for the 6-month period of administration. Melatonin was well tolerated in all patients and no side effects were noted during the therapy. Melatonin appears to be promising as an efficient and seemingly safe alternative for treatment of severe circadian sleep disturbances in adults with autism. There may be heterogeneity of response depending on the nature of the sleep problem and cause of the intellectual disability or associated disabilities. Further studies are necessary before firm conclusions can be drawn and guidelines for the use of melatonin in people with autism formulated.

Melatonin in treatment of chronic sleep disorders in adults with autism: a retrospective study.

Melatonin may be used to treat sleep disorders in both children and adults with intellectual disability. The evidence for its efficacy, potential adverse effects and drug interactions are reviewed in the context of prescription of melatonin to patients with autism. This study presents the use of melatonin to treat severe circadian sleep-wake disturbances in 6 adults with autism. Melatonin was initiated at a daily dose of 3 mg at nocturnal bedtime. If this proved ineffective, the melatonin dose was titrated over the following 4 weeks at increments of 3 mg/2 weeks up to a maximum of 9 mg, unless it was tolerated. Assessments included Clinical Global Impression-Severity (CGI-S) and CGI-Improvement (CGI-I). Melatonin administered in the evening dramatically improved the sleep-wake pattern in all patients. Melatonin appears to be effective in reducing sleep onset latency and is probably effective in improving nocturnal awakenings and total sleep time in adults with autism. Its effectiveness remained stable for the 6-month period of administration. Melatonin was well tolerated in all patients and no side effects were noted during the therapy. Melatonin appears to be promising as an efficient and seemingly safe alternative for treatment of severe circadian sleep disturbances in adults with autism. There may be heterogeneity of response depending on the nature of the sleep problem and cause of the intellectual disability or associated disabilities. Further studies are necessary before firm conclusions can be drawn and guidelines for the use of melatonin in people with autism formulated.

P03-224 Melatonin in treatment of chronic sleep disorders in adults with pervasive development disorders: A retrospective study

Background:Melatonin may be used to treat sleep disorders in both children and adults with intellectual disability. the evidence for its efficacy, potential adverse effects and drug interactions are reviewed in the context of prescribing to people with intellectual disability.Methods:This study presents the use of melatonin to treat severe circadian sleep-wake disturbances in 6 adults with pervasive developmental disorders. Melatonin was initiated at a daily dose of 3 mg at nocturnal bedtime. If this proved ineffective, the melatonin dose was titrated over the following 4 weeks at increments of 3mg/2weeks up to a maximum of 9 mg, unless it was tolerated. Assessments included the Clinical Global Impression-Severity (CGI-S) and CGI-Improvement (CGI-I).Results:Melatonin administered in the evening dramatically improved the sleep-wake pattern in all patients. Melatonin appears to be effective in reducing sleep onset latency and is probably effective in improving nocturnal awakenings and total sleep time in adults with pervasive developmental disorders. Its effectiveness remained stable for the 6-months period of administration. Melatonin was well-tolerated in all patients and no side effects were noted during the therapy.Conclusions:Melatonin appears to be promising as an efficient and seemingly safe alternative for treatment of severe circadian sleep disturbances in adults with intellectual disability. There may be heterogeneity of response depending on the nature of the sleep problem and cause of the intellectual disability or associated disabilities. Further studies are necessary before firm conclusions can be drawn and guidelines for the use of melatonin for people with ID formulated.

Neuroimaging insights into the pathophysiology of sleep disorders.

Neuroimaging methods can be used to investigate whether sleep disorders are associated with specific changes in brain structure or regional activity. However, it is still unclear how these new data might improve our understanding of the pathophysiology underlying adult sleep disorders. Here we review functional brain imaging findings in major intrinsic sleep disorders (i.e., idiopathic insomnia, narcolepsy, and obstructive sleep apnea) and in abnormal motor behavior during sleep (i.e., periodic limb movement disorder and REM sleep behavior disorder). The studies reviewed include neuroanatomical assessments (voxel-based morphometry, magnetic resonance spectroscopy), metabolic/functional investigations (positron emission tomography, single photon emission computed tomography, functional magnetic resonance imaging), and ligand marker measurements. Based on the current state of the research, we suggest that brain imaging is a useful approach to assess the structural and functional correlates of sleep impairments as well as better understand the cerebral consequences of various therapeutic approaches. Modem neuroimaging techniques therefore provide a valuable tool to gain insight into possible pathophysiological mechanisms of sleep disorders in adult humans.

The use of melatonin to treat sleep disorder in adults with intellectual disabilities in community settings – the evaluation of three cases using actigraphy

Sleep disorders are known to be very prevalent in adults with intellectual disabilities (ID) but to date there has been limited objective assessment of either sleep disorders or of interventions such as the use of melatonin. A protocol-driven assessment and intervention procedure was followed with three people with moderate to severe ID identified as having a possible sleep disorder. Actigraphic assessment was used to determine the nature of the sleep disorder, after which sleep hygiene advice and then individual treatment with melatonin were provided, following which further actigraphic assessment was carried out. Behavioural disturbance was formally assessed before and after the intervention phase. Following treatment with melatonin, changes in circadian rhythm were noted, together with improvements in challenging behaviour, but no significant effects were noted with regard to either quantity or quality of sleep. A standardised procedure for assessment and treatment of sleep disorders in people with ID was established. Although no apparent effects on sleep quantity or quality were noted, this may reflect factors inherent in the sample, rather than the relative efficacy of melatonin treatment per se.

A case of restless legs syndrome in a child presenting with growing pains

Restless legs syndrome (RLS) is a common neurological sleep disorder in adults characterized by the following diagnostic criteria: an urge to move that is usually associated with unpleasant sensations and symptoms that are worse at rest, relieved by movement, and most severe at night. The definite diagnosis of RLS in children is stricter and consists of self-description of leg discomfort or the presence of 2 of 3 supportive criteria combined with 4 essential criteria for diagnosis in adults. RLS in childhood has often been misdiagnosed as growing pains or a part of normal development. As a result, physicians have often missed the chance for proper management. We diagnosed a case of RLS in a 5-year-old boy presenting with growing pains, whose mother was found to have had RLS since childhood. We confirmed RLS by using a polysomnograph, in which the indices of periodic limb movement syndrome (PLMS) and periodic limb movement during wakefulness (PLMW) were recorded to be compatible with RLS criteria. The patient‘s ferritin level was low normal, and his symptoms improved after taking iron supplements.

Sleep and sleep disorders in adults with attention deficit/hyperactivity disorder

Attention deficit/hyperactivity disorder (ADHD) is a frequent disorder that often persists in adulthood. Persistent ADHD is known to be a serious risk factor for other disorders in adulthood, and adults with ADHD often report on sleep disorders. Despite this, only few studies have investigated the subjective and objective quality of sleep in adults suffering from ADHD. Previous studies have revealed seriously impaired subjective sleep quality and increased nocturnal motor activity in spite of essentially normal standard polysomnographic parameters in this patient group. However, primary sleep disorders such as sleep apnea syndrome or restless legs syndrome (RLS) may be misdiagnosed as ADHD. Moreover, ADHD and primary sleep disorders may occur as comorbidities. In particular, RLS was suggested to be highly associated with ADHD, indicating a probable common central nervous dopaminergic dysfunction. To date, larger studies with adequate sample sizes that compare sleep in adult patients with ADHD, healthy control groups and patients with other primary sleep disorders are still lacking.

Exploration du sommeil chez l'adulte et l'adolescent

This article provides recommendations for clinicians concerning the investigations related to sleep disorders in adults and adolescents. Evaluation begins with clinical examination, including interviews of the patient and his family. Additional tests are often recommended to identify sleep disorder. Different tools are presented, useful in investigating sleep (polysomnography, actigraphy, questionnaires, sleep logs), and sleepiness (24h polysomnography, multi sleep latency test, maintenance of wakefulness test, sleepiness scales). We describe also the diagnostic steps for insomnia, excessive daytime sleepiness, circadian rhythm disorders, and parasomnia.

Insomnia: Conceptual Issues in the Development, Persistence, and Treatment of Sleep Disorder in Adults

This paper critically reviews the evidence base for previously reported conceptual models of the development and persistence of insomnia. Although a number of perspectives have some empirical support, no one approach emerges as preeminent. Importantly, the efficacy of any particular psychological intervention cannot be taken as confirmation of presumed, underlying mechanisms. An integrated psychobiological inhibition model of insomnia is developed that accounts for the research data. The model views insomnia as arising from inhibition of de-arousal processes associated with normal sleep. It is proposed that sleep homeostatic and circadian factors are compromised by impairment of the automaticity and plasticity associated with good sleep, and that cognitive/affective processes activate the clinical complaint of insomnia. Common pathways for the action of cognitive-behavioral interventions are identified, and a research agenda is set for further conceptual and clinical study.