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Abstract
OBJECTIVES To document the frequency of insomnia (according to DSM-IV and ICSD criteria), to describe its sociodemographic and clinical characteristics, and to identify potential predictors of insomnia in persons with traumatic brain injury (TBI). PARTICIPANTS AND PROCEDURE: Four hundred fifty-two participants aged 16 years and older with minor to severe TBI answered a questionnaire pertaining to quality of sleep and fatigue. MAIN OUTCOME MEASURES Proportion of participants fulfilling criteria for insomnia symptoms or syndrome. Validated measures of insomnia severity, fatigue level, and psychologic distress. Results of a logistic regression analysis. RESULTS Overall, 50.2% of the sample reported insomnia symptoms and 29.4% fulfilled the diagnostic criteria for an insomnia syndrome. For the latter participants, insomnia was a severe and chronic condition remaining untreated in almost 60% of cases. Risk factors associated with insomnia were milder TBIs, and higher levels of fatigue, depression, and pain. CONCLUSION Insomnia is a prevalent condition after TBI requiring more clinical and scientific attention as it may have important repercussions on rehabilitation.
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Abstract
Macrostructure describes the temporal organization of sleep based on successive epochs of conventional length, while microstructure, which is analyzed on the basis of the scoring of phasic events, provides additional important dynamic characteristics in the evaluation of both normal and pathological sleep processes. Relationships between sleep, sleep disorders, and psychiatric disorders are quite complex, and it clearly appears that both the macrostructure and the microstructure of sleep are valuable physiologically and clinically. Psychiatric patients often complain about their sleep, and they may show sleep abnormalities that increase with the severity of their illness. Changes in the occurrence and frequency of phasic events during sleep may be associated with specific psychiatric disorders, and may provide valuable information for both diagnosis and prognosis of these disorders.
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Affiliation(s)
- Alain Muzet
- Centre National de la Recherche Scientifique, CNRS-CEPA, Strasbourg, France.
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53
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Abstract
OBJECTIVE Primary insomnia is one of the most prevalent sleep disorders and assumed to be initiated and maintained, among other factors, by psychological variables such as coping strategies, sleep hygiene techniques, and arousability. Althouugh the number and kind of stressors seem to be important initiators of insomnia, individual coping dispositions appear to play a larger role in maintaining it. This study explores the relationship between different coping dispositions (monitoring/blunting) and insomnia. Monitoring refers to information-seeking behavior under threat; blunting pertains to distractive strategies utilized in situations implying threat or danger. METHODS The study compares 37 primary insomniacs (DSM IV criteria) and 47 good sleepers. Dependent measures included self-rating scales concerning sleep quality (Schlaffragebogen part B, Frankfurter Schlaffragebogen), coping styles (Frankfurt Monitoring Blunting Scales), and psychopathology (Neo Five Factors Inventory, Beck Anxiety Inventory). All measures had documented psychometric properties. RESULTS Primary insomniacs were significantly more likely to rigidly resort to monitoring strategies in controllable as well as uncontrollable situations. Further, 73% of all rigid monitors identified in the sample were rated as primary insomniacs, whereas 86% of all rigid Blunters were good sleepers. Insomniacs showed higher levels of anxiety than good sleepers, coping style groups differed in anxiety and neuroticism scores. CONCLUSION The study further supports the hypothesis that a monitoring coping style is related to primary insomnia. Blunting appears to be a good predictor of high sleep quality. The results are discussed with regard to improving treatment for patients suffering from primary insomnia.
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Affiliation(s)
- Ursula Voss
- Institute of Psychology, J. W. Goethe-Universität, Frankfurt am Main, Germany.
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Savard J, Simard S, Ivers H, Morin CM. Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part II: Immunologic effects. J Clin Oncol 2005; 23:6097-106. [PMID: 16135476 DOI: 10.1200/jco.2005.12.513] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Cross-sectional studies suggest that clinical insomnia is associated with immune downregulation. However, there is a definite need for experimental studies on this question. The goal of this randomized controlled study was to assess the effect of an 8-week cognitive-behavioral therapy (CBT) for chronic insomnia on immune functioning of breast cancer survivors. Previous analyses of this study showed that CBT was associated with improved sleep and quality of life, and reduced psychological distress. PATIENTS AND METHODS Fifty-seven women with chronic insomnia secondary to breast cancer were randomly assigned to CBT (n = 27) or to a waiting-list control condition (WLC; n = 30). Peripheral-blood samples were taken at baseline and post-treatment (and postwaiting for WLC patients), as well as at 3-, 6-, and 12-month follow-up for immune measures, including enumeration of blood cell counts (ie, WBCs, monocytes, lymphocytes, CD3+, CD4+, CD8+, and CD16+/CD56+) and cytokine production (ie, interleukin-1-beta [IL-1beta] and interferon gamma [IFN-gamma]). RESULTS Patients treated with CBT had higher secretion of IFN-gamma and lower increase of lymphocytes at post-treatment compared with control patients. Pooled data from both treated groups indicated significantly increased levels of IFN-gamma and IL-1beta from pre- to post-treatment. In addition, significant changes in WBCs, lymphocytes, and IFN-gamma were found at follow-up compared with post-treatment. CONCLUSION This study provides some support to the hypothesis of a causal relationship between clinical insomnia and immune functioning. Future studies are needed to investigate the clinical impact of such immune alterations.
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Affiliation(s)
- Josée Savard
- Laval University Cancer Research Center, 11 Côte du Palais, Québec, Québec, Canada, G1R 2J6.
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56
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Kaplow R. Sleep Deprivation and Psychosocial Impact in Acutely Ill Cancer Patients. Crit Care Nurs Clin North Am 2005; 17:225-37. [PMID: 16115530 DOI: 10.1016/j.ccell.2005.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Sleep is an important factor related to health and quality of life for all individuals. For people with cancer, sleep disturbances are common and are a source of distress. This article summarizes the problems and reviews the types, prevalence, etiology, risk factors, clinical sequelae, and management of sleep disturbances experienced by cancer patients. A comprehensive review of the literature is presented, along with direction for nursing practice and research.
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Affiliation(s)
- Roberta Kaplow
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta, GA 30322-4207, USA.
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57
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Savard J, Simard S, Hervouet S, Ivers H, Lacombe L, Fradet Y. Insomnia in men treated with radical prostatectomy for prostate cancer. Psychooncology 2005; 14:147-56. [PMID: 15386779 DOI: 10.1002/pon.830] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study assessed the prevalence, clinical characteristics and risk factors for insomnia in patients treated with radical prostatectomy for prostate cancer. A total of 327 patients completed a battery of questionnaires assessing sleep and related issues (i.e. anxiety, depression, fatigue, quality of life). Results indicated that 31.5% of the patients currently reported non-specific sleep difficulties, while 18% met specific criteria for an insomnia syndrome. In most of these latter cases (95%), the insomnia was chronic (duration of 6 months or more). Nearly half of patients with an insomnia syndrome reported that the onset of their sleep difficulties followed the cancer diagnosis. A similar proportion had no comorbid clinical levels of anxiety or depression. Risk factors for the presence of an insomnia syndrome included a younger age, a worse prognosis, and the presence of intestinal, pain, depressive, and androgen blockade-related symptoms. Thus, insomnia is a frequent problem associated with prostate cancer, that often occurs independently of anxiety and depression, but seems to be influenced by the presence of physical and psychological symptoms associated with prostate cancer and its treatment.
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Affiliation(s)
- Josée Savard
- Laval University Cancer Research Center and School of Psychology, Université Laval, Québec, Canada.
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58
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Markus CR, Jonkman LM, Lammers JHCM, Deutz NEP, Messer MH, Rigtering N. Evening intake of alpha-lactalbumin increases plasma tryptophan availability and improves morning alertness and brain measures of attention. Am J Clin Nutr 2005; 81:1026-33. [PMID: 15883425 DOI: 10.1093/ajcn/81.5.1026] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Brain serotonin function is thought to promote sleep regulation and cognitive processes, whereas sleep abnormalities and subsequent behavioral decline are often attributed to deficient brain serotonin activity. Brain uptake of the serotonin precursor tryptophan is dependent on nutrients that influence the availability of tryptophan via a change in the ratio of plasma tryptophan to the sum of the other large neutral amino acids (Trp:LNAA). OBJECTIVE We tested whether evening consumption of alpha-lactalbumin protein with an enriched tryptophan content of 4.8 g/100 g increases plasma Trp:LNAA and improves alertness and performance on the morning after sleep, particularly in subjects with sleep complaints. DESIGN Healthy subjects with (n = 14) or without (n = 14) mild sleep complaints participated in a double-blind, placebo-controlled study. The subjects slept at the laboratory for 2 separate nights so that morning performance could be evaluated after an evening diet containing either tryptophan-rich alpha-lactalbumin or tryptophan-low placebo protein. Evening dietary changes in plasma Trp:LNAA were measured. Behavioral (reaction time and errors) and brain measures of attention were recorded during a continuous performance task. RESULTS Evening alpha-lactalbumin intake caused a 130% increase in Trp:LNAA before bedtime (P = 0.0001) and modestly but significantly reduced sleepiness (P = 0.013) and improved brain-sustained attention processes (P = 0.002) the following morning. Only in poor sleepers was this accompanied by improved behavioral performance (P = 0.05). CONCLUSION Evening dietary increases in plasma tryptophan availability for uptake into the brain enhance sustained alertness early in the morning after an overnight sleep, most likely because of improved sleep.
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Affiliation(s)
- C Rob Markus
- Department of Experimental Psychology and the Biomedical Center, University of Maastricht, Maastricht, Netherlands.
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Dauvilliers Y, Morin C, Cervena K, Carlander B, Touchon J, Besset A, Billiard M. Family studies in insomnia. J Psychosom Res 2005; 58:271-8. [PMID: 15865952 DOI: 10.1016/j.jpsychores.2004.08.012] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2004] [Accepted: 08/18/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Several predisposing factors to insomnia have been hypothesized, including a familial component; however, few studies have focused on this topic. The aim of this study is to evaluate the prevalence of insomnia among first-degree relatives of chronic insomniacs and to compare the symptoms between sporadic and familial insomnia. METHODS Two hundred fifty-six consecutive chronic insomniacs completed a clinical interview, psychometric questionnaires, a questionnaire on the family history of insomnia and, when indicated, a polysomnography. A control group was performed to estimate a base-rate incidence of insomnia in their families. RESULTS Patients with primary (n=77) and psychiatric (n=104) insomnia were definitely included. Of those with primary insomnia, 72.7% reported familial insomnia compared with 24.1% in the noninsomnia control group. Among the psychiatric insomniacs, 43.3% reported familial insomnia. The mother was the relative most frequently affected. Comparisons between the family prevalence rates of insomnia assessed by the probands and by first-degree relatives show high concordance. A tendency to a younger age at onset was observed in familial and primary insomnia. CONCLUSION This study reports a significant increase of familial aggregation of insomnia, warranting further genetic studies in primary insomnia with early age at onset.
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Affiliation(s)
- Yves Dauvilliers
- Service de Neurologie B, Hôpital Gui-de-Chauliac, 80 Avenue Augustin Fliche, Montpellier cedex 5 34295, France.
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60
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Bélanger L, Morin CM, Langlois F, Ladouceur R. Insomnia and generalized anxiety disorder: effects of cognitive behavior therapy for gad on insomnia symptoms. J Anxiety Disord 2004; 18:561-71. [PMID: 15149714 DOI: 10.1016/s0887-6185(03)00031-8] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2002] [Revised: 10/08/2002] [Accepted: 04/16/2003] [Indexed: 10/27/2022]
Abstract
Although clinical practice suggests that sleep complaints are frequent among patients with generalized anxiety disorder (GAD), frequency, severity, types of insomnia complaints, and relationship to GAD diagnosis severity in patients diagnosed using Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria are not well documented. Clinical data about the impact on insomnia symptoms of treating GAD worries are also lacking. The present study examined these aspects in 44 GAD patients who participated in a treatment study specifically addressing excessive worries through CBT interventions. All patients were assessed using a structured clinical interview and the Anxiety Disorder Interview Schedule-IV (ADIS-IV). They also completed anxiety and insomnia inventories, including the Insomnia Severity Index (ISI), a self-report measure which assesses insomnia type, severity and interference with daily life. Among this sample, 47.7% reported difficulties initiating sleep, 63.6% reported difficulties maintaining sleep, and 56.8% complained of waking too early in the morning. The majority of these patients (86.5%) reported never having experienced insomnia without having excessive worries. However, insomnia severity and GAD severity were not correlated. In this sample, patients with severe GAD did not necessarily report more severe insomnia symptoms. Regarding treatment impact on insomnia complaints, ISI post-treatment scores were significantly lower after treatment. Mean post-treatment scores almost reached ISI's "absence of clinical insomnia" category. Results indicate that this CBT package for GAD does have a significant impact on sleep quality even if sleep disturbances were not specifically addressed during treatment.
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Affiliation(s)
- Lynda Bélanger
- Ecole de Psychologie, Université Laval, Laval, Que., Canada G1K 7P4.
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Belleville G, Bélanger L, Morin CM. Le traitement cognitivo-comportemental de l’insomnie et son utilisation lors de l’arrêt des hypnotiques. SANTE MENTALE AU QUEBEC 2004. [DOI: 10.7202/008618ar] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Résumé
L’insomnie constitue un problème de santé très répandu menant souvent à l’utilisation d’hypnotiques. Parmi les agents pharmacologiques disponibles pour traiter l’insomnie, les benzodiazépines (BZD) sont les plus prescrites. Bien qu’efficaces pour améliorer le sommeil à court terme, les BZD présentent certains effets indésirables, entraînent des risques de tolérance et de dépendance, et augmentent le risque d’accidents de la route, de chutes et de fractures chez les personnes âgées. Le traitement cognitivo-comportemental (TCC) de l’insomnie, qui met l’accent sur les facteurs psychologiques et comportementaux jouant un rôle dans le maintien des difficultés de sommeil, est efficace pour améliorer le sommeil des personnes aux prises avec un trouble d’insomnie primaire. Il peut représenter une alternative à la pharmacothérapie ou encore être un complément thérapeutique facilitant lors de l’arrêt des hypnotiques. Le TCC de l’insomnie peut inclure différentes composantes, telles que le contrôle par le stimulus, la restriction du sommeil, la relaxation, la restructuration cognitive et l’hygiène du sommeil. Chez les personnes dépendantes aux BZD ou autres hypnotiques, un sevrage supervisé, basé sur l’atteinte d’objectifs successifs, s’ajoute généralement au TCC de l’insomnie.
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Abstract
Significant efforts have been made in the last decade to develop evidence-based guidelines for the treatment of insomnia and other sleep disorders. Despite such progress, there are still no standard assessment methods to document outcome and no accepted criteria to define what should be a successful outcome in the treatment of insomnia. This paper reviews methodological and conceptual issues related to the measurement of outcomes in clinical trials of insomnia. Selected studies of behavioral and pharmacological therapies of insomnia are summarized to illustrate the types of dependent variables and assessment instruments used to document treatment efficacy. Additional outcome variables and assessment methods of potential interest are discussed, and criteria for interpreting and reporting outcomes are summarized. As most studies have relied on fairly narrow criteria to define an effective treatment, the need to broaden the scope of outcome assessment is highlighted. For instance, it is essential to document treatment efficacy beyond the simple reduction of insomnia symptoms and to incorporate additional indicators of success. Given that insomnia is associated with significant morbidity, an effective treatment should not only improve sleep parameters, but it should also produce clinically meaningful changes in daytime functioning, fatigue, mood, and quality of life. The need to evaluate outcome from multiple perspectives and to develop a core-assessment battery that would consider efficacy, clinical significance, and cost-effectiveness are discussed.
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63
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Quesnel C, Savard J, Simard S, Ivers H, Morin CM. Efficacy of cognitive-behavioral therapy for insomnia in women treated for nonmetastic breast cancer. J Consult Clin Psychol 2003. [DOI: 10.1037/0022-006x.71.1.189] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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64
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Garma L. Insomnias associated with psychiatric disorders. Sleep 2003. [DOI: 10.1007/978-1-4615-0217-3_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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65
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Shapiro SL, Bootzin RR, Figueredo AJ, Lopez AM, Schwartz GE. The efficacy of mindfulness-based stress reduction in the treatment of sleep disturbance in women with breast cancer: an exploratory study. J Psychosom Res 2003; 54:85-91. [PMID: 12505559 DOI: 10.1016/s0022-3999(02)00546-9] [Citation(s) in RCA: 244] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The diagnosis of breast cancer, the most common type of cancer among American women, elicits greater distress than any other diagnosis regardless of prognosis. Therefore, the present study examined the efficacy of a stress reduction intervention for women with breast cancer. METHODS As part of a larger, randomized, controlled study of the effects on measures of stress of a mindfulness-based stress reduction (MBSR) intervention for women with breast cancer, the current analyses examined the effects on sleep complaints. RESULTS Analyses of the data indicated that both MBSR and a free choice (FC) control condition produced significant improvement on daily diary sleep quality measures though neither showed significant improvement on sleep-efficiency. Participants in the MBSR who reported greater mindfulness practice improved significantly more on the sleep quality measure most strongly associated with distress. CONCLUSION MBSR appears to be a promising intervention to improve the quality of sleep in woman with breast cancer whose sleep complaints are due to stress.
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Affiliation(s)
- Shauna L Shapiro
- Department of Psychology, University of Arizona, Tucson, AZ 85721, USA.
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66
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Abstract
Insomnia is one of the most prevalent psychological disorders, causing sufferers severe distress as well as social, interpersonal, and occupational impairment. Drawing on well-validated cognitive models of the anxiety disorders as well as on theoretical and empirical work highlighting the contribution of cognitive processes to insomnia, this paper presents a new cognitive model of the maintenance of insomnia. It is suggested that individuals who suffer from insomnia tend to be overly worried about their sleep and about the daytime consequences of not getting enough sleep. This excessive negatively toned cognitive activity triggers both autonomic arousal and emotional distress. It is proposed that this anxious state triggers selective attention towards and monitoring of internal and external sleep-related threat cues. Together, the anxious state and the attentional processes triggered by it tricks the individual into overestimating the extent of the perceived deficit in sleep and daytime performance. It is suggested that the excessive negatively toned cognitive activity will be fuelled if a sleep-related threat is detected or a deficit perceived. Counterproductive safety behaviours (including thought control, imagery control, emotional inhibition, and difficulty problem solving) and erroneous beliefs about sleep and the benefits of worry are highlighted as exacerbating factors. The unfortunate consequence of this sequence of events is that the excessive and escalating anxiety may culminate in a real deficit in sleep and daytime functioning. The literature providing preliminary support for the model is reviewed and the clinical implications and limitations discussed.
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Affiliation(s)
- A G Harvey
- Department of Experimental Psychology, University of Oxford, UK.
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67
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Abstract
This article reviews the evidence on the diagnosis, epidemiology, etiology, and treatment of insomnia in the context of cancer and proposes several areas for future research. Clinical and diagnostic features of insomnia are described and prevalence estimates of insomnia complaints in cancer patients are summarized. Then, potential etiologic factors (ie, predisposing, precipitating, and perpetuating factors) and consequences of insomnia (ie, psychologic, behavioral, and health impact) in the context of cancer are discussed. Finally, pharmacologic and psychologic treatments previously shown effective to treat insomnia in healthy individuals are discussed as valuable treatment options for cancer patients as well. Because long-term use of hypnotic medications is associated with some risks (eg, dependence), it is argued that psychologic interventions (eg, stimulus control, sleep restriction, cognitive therapy) are the treatment of choice for sleep disturbances in the context of cancer, especially when it has reached a chronic course. However, the efficacy of these treatments has yet to be verified specifically in cancer patients.
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Affiliation(s)
- J Savard
- Laval University Cancer Research Center, Université Laval, Québec, Québec, Canada.
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68
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Monti JM, Monti D. Sleep disturbance in generalized anxiety disorder and its treatment. Sleep Med Rev 2000; 4:263-276. [PMID: 12531169 DOI: 10.1053/smrv.1999.0096] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Sleep laboratory and epidemiological studies indicate that insomnia is a frequent finding in patients with psychiatric disorders. In this respect, insomnia associated with a major depression or an anxiety disorder, mainly generalized anxiety disorder (GAD), is the most prevalent diagnosis. According to available evidence, the sleep disturbance associated with mild-to-moderate GAD is a sleep-maintenance insomnia, and to a lesser extent a sleep-onset insomnia. Insomnia associated with mild-to-moderate GAD generally responds to psychological treatments and anxiolytic benzodiazepines. Moreover, concomitant administration of hypnotic medication can be contemplated in patients with severe GAD.
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Affiliation(s)
- Jaime M. Monti
- Clinical Pharmacology and Therapeutics, Clinics Hospital, Montevideo, Uruguay
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69
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Abstract
A insônia primária é uma dissonia caracterizada pela dificuldade em iniciar e/ou manter o sono e pela sensação de não ter um sono reparador durante um período não inferior a 1 mês. Do ponto de vista polissonográfico, é acompanhada de alterações na indução, na continuidade e na estrutura do sono. Geralmente aparece no adulto jovem, é mais freqüente na mulher e tem um desenvolvimento crônico. A insônia primária é observada de 12,5% a 22,2% dos pacientes portadores de insônia crônica, sendo precedida em freqüência somente na insônia de depressão maior. A insônia primária crônica deve se diferenciar da insônia vinculada a uma higiene inadequada do sono, uma síndrome depressiva ou um transtorno de ansiedade generalizado. O tratamento da insônia primária inclui: higiene adequada do sono, terapia cognitiva e de conduta e uso de fármacos hipnóticos. Entre esses últimos, se destacam o zolpidem e a zopiclona, que melhoram significativamente o sono sem alterar sua estrutura ou induzir a uma reincidência da insônia logo após uma interrupção brusca. Além disso, o desenvolvimento de fármaco-dependência e de vício é muito pouco freqüente.
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70
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Psychological and pharmacological approaches to treating insomnia: Critical issues in assessing their separate and combined effects. Clin Psychol Rev 1996. [DOI: 10.1016/0272-7358(96)00027-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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