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Marques DR, Gomes AA, de Azevedo MHP. Daytime sleepiness in insomnia: Are we focusing on what truly matters? Chronobiol Int 2024; 41:1068-1080. [PMID: 39007884 DOI: 10.1080/07420528.2024.2378025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 06/12/2024] [Accepted: 07/04/2024] [Indexed: 07/16/2024]
Abstract
Insomnia, the most prevalent sleep disorder, is commonly associated with other mental and somatic disorders, making it a significant health concern. It is characterized by nighttime symptoms and daytime dysfunction, with sleepiness being a potential criterion for the latter. Sleepiness is a normal physiological state that is typically experienced near usual bedtime, in normal circumstances. In insomnia, it seems somewhat logical the idea that there is significant daytime sleepiness. However, the topic has been the subject of various discussions in sleep medicine, with studies yielding contradictory and inconsistent results. In this article, we aim to critically examine daytime sleepiness in individuals with insomnia disorder and propose an alternative approach to addressing it, both in clinical practice and research settings. It is crucial to further investigate the role of daytime sleepiness in insomnia, particularly by focusing on sleepiness perception as a more relevant dimension to explore in majority of patients. It is plausible that certain insomnia phenotypes are objectively sleepy during the day, but more studies are necessary, particularly with well-defined clinical samples. The implications of assessing sleepiness perception in insomnia for clinical practice are discussed, and new avenues for research are suggested.
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Affiliation(s)
- Daniel Ruivo Marques
- Department of Education and Psychology, Campus Universitário de Santiago, University of Aveiro, Aveiro, Portugal
- CINEICC - Center for Research in Neuropsychology and Cognitive Behavioral Intervention, Faculty of Psychology and Educational Sciences, University of Coimbra, Coimbra, Portugal
| | - Ana Allen Gomes
- CINEICC - Center for Research in Neuropsychology and Cognitive Behavioral Intervention, Faculty of Psychology and Educational Sciences, University of Coimbra, Coimbra, Portugal
- Faculty of Psychology and Educational Sciences, University of Coimbra, Coimbra, Portugal
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2
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Nyhuis CC, Fernandez-Mendoza J. Insomnia nosology: a systematic review and critical appraisal of historical diagnostic categories and current phenotypes. J Sleep Res 2023; 32:e13910. [PMID: 37122153 DOI: 10.1111/jsr.13910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 05/02/2023]
Abstract
Insomnia nosology has significantly evolved since the Diagnostic and Statistical Manual (DSM)-III-R first distinguished between 'primary' and 'secondary' insomnia. Prior International Classification of Sleep Disorders (ICSD) nosology 'split' diagnostic phenotypes to address insomnia's heterogeneity and the DSM nosology 'lumped' them into primary insomnia, while both systems assumed causality for insomnia secondary to health conditions. In this systematic review, we discuss the historical phenotypes in prior insomnia nosology, present findings for currently proposed insomnia phenotypes based on more robust approaches, and critically appraise the most relevant ones. Electronic databases PsychINFO, PubMED, Web of Science, and references of eligible articles, were accessed to find diagnostic manuals, literature on insomnia phenotypes, including systematic reviews or meta-analysis, and assessments of the reliability or validity of insomnia diagnoses, identifying 184 articles. The data show that previous insomnia diagnoses lacked reliability and validity, leading current DSM-5-TR and ICSD-3 nosology to 'lump' phenotypes into a single diagnosis comorbid with health conditions. However, at least two new, robust insomnia phenotyping approaches were identified. One approach is multidimensional-multimethod and provides evidence for self-reported insomnia with objective short versus normal sleep duration linked to clinically relevant outcomes, while the other is multidimensional and provides evidence for two to five clusters (phenotypes) based on self-reported trait, state, and/or life-history data. Some approaches still need replication to better support whether their findings identify true phenotypes or simply different patterns of symptomatology. Regardless, these phenotyping efforts aim at improving insomnia nosology both as a classification system and as a mechanism to guide treatment.
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Affiliation(s)
- Casandra C Nyhuis
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Julio Fernandez-Mendoza
- Sleep Research and Treatment Center, Department of Psychiatry and Behavioral Health, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
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3
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Altena E, Ellis J, Camart N, Guichard K, Bastien C. Mechanisms of cognitive behavioural therapy for insomnia. J Sleep Res 2023; 32:e13860. [PMID: 36866434 DOI: 10.1111/jsr.13860] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/03/2023] [Accepted: 02/03/2023] [Indexed: 03/04/2023]
Abstract
Although much is known now about behavioural, cognitive and physiological consequences of insomnia, little is known about changes after cognitive behavioural therapy for insomnia on these particular factors. We here report baseline findings on each of these factors in insomnia, after which we address findings on their changes after cognitive behavioural therapy. Sleep restriction remains the strongest determinant of insomnia treatment success. Cognitive interventions addressing dysfunctional beliefs and attitudes about sleep, sleep-related selective attention, worry and rumination further drive effectiveness of cognitive behavioural therapy for insomnia. Future studies should focus on physiological changes after cognitive behavioural therapy for insomnia, such as changes in hyperarousal and brain activity, as literature on these changes is sparse. We introduce a detailed clinical research agenda on how to address this topic.
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Affiliation(s)
| | - Jason Ellis
- Northumbria Centre for Sleep Research, Northumbria University, Newcastle, UK
| | - Nathalie Camart
- UR CLIPSYD, UFR SPSE, Département de psychologie, Université Paris Nanterre, Nanterre, France
- Cabinet Pôle Psy République, Bordeaux, France
- Nouvelle Clinique Bel Air- PEAS, Bordeaux, France
| | - Kelly Guichard
- Nouvelle Clinique Bel Air- PEAS, Bordeaux, France
- CHU Bordeaux, Centre Hypersomnies Rares, Bordeaux, France
| | - Célyne Bastien
- Ecole de Psychologie, Université Laval, Québec, Québec, Canada
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Pereira R, Hartescu I, Jackson RC, Morgan K. Napping behaviour, daytime sleepiness, and arousal in high performance athletes and non-athlete controls. J Sports Sci 2023; 41:1530-1537. [PMID: 37953624 DOI: 10.1080/02640414.2023.2281158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 11/01/2023] [Indexed: 11/14/2023]
Abstract
Napping offers a strategy to manage sleep, aid recovery and enhance performance in elite sport. However, relatively little research attention has focussed on the natural history of athlete napping or tested the widely held assumption that athlete napping is mainly a consequence of degraded night-time sleep. Within a sample of 158 team (n = 76) and individual (n = 80) sport athletes, and 82 non-athlete controls, we analysed napping behaviour in relation to sleep quality, daytime sleepiness, and pre-sleep somatic and cognitive arousal. There was no significant association between athlete/non-athlete status and the prevalence, frequency, or duration of naps. Comparisons of athlete nappers and non-nappers found no significant differences in sleep quantity or quality. While nap propensity was significantly related to higher daytime sleepiness, this influence was moderated or augmented by levels of pre-sleep cognitive arousal. For some nappers, those with higher levels of arousal may need to be sleepier than those with lower levels of arousal in order to successfully initiate daytime sleep. Approximately 50% of athletes did not nap. If the benefits of athlete napping are to be fully exploited, the needs of this substantial group for whom napping may be problematic should be recognised and addressed.
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Affiliation(s)
- Rui Pereira
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, Leicestershire, UK
| | - Iuliana Hartescu
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, Leicestershire, UK
| | - Robin C Jackson
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, Leicestershire, UK
| | - Kevin Morgan
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, Leicestershire, UK
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Badon SE, Dietch JR, Simpson N, Lyell DJ, Manber R. Daytime napping and nighttime sleep in pregnant individuals with insomnia disorder. J Clin Sleep Med 2023; 19:371-377. [PMID: 36448328 PMCID: PMC9892727 DOI: 10.5664/jcsm.10350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 12/02/2022]
Abstract
STUDY OBJECTIVES Examine bidirectional associations between daytime napping and nighttime sleep among pregnant individuals with insomnia disorder. METHODS We used baseline data from a randomized controlled trial of insomnia treatment during pregnancy (n = 116). Participants in their second or third trimester of pregnancy self-reported daytime napping and nighttime sleep parameters using a sleep diary and wore an Actiwatch-2 during the same 7-day period. Linear regression models, accounting for intraindividual correlation, were used to estimate associations between daytime napping and nighttime sleep parameters (duration, efficiency, quality, awakenings). Models were also stratified by trimester of pregnancy. RESULTS Sixty-three percent of participants reported napping on at least 1 day. Among participants in the second trimester (65%), napping 15-59 minutes was associated with 6.3% greater self-reported sleep efficiency (95% confidence interval: 2.3, 10.2) and 0.5 units greater self-reported sleep quality (95% confidence interval: 0.0, 0.9) that night; napping 60+ minutes was associated with 0.6 hours shorter actigraphy-measured sleep duration (95% confidence interval: -1.0, -0.2). Napping was not associated with nighttime sleep overall or during the third trimester. Nighttime sleep parameters were not associated with napping duration the following day. CONCLUSIONS Among pregnant individuals with insomnia in the second trimester, short napping duration was associated with higher self-reported sleep efficiency and quality; long napping duration was associated with shorter actigraphy-measured sleep duration. Additional research is needed to examine the interaction between nap duration and nap timing. In the future, these results may lead to more nuanced recommendations for daytime napping among pregnant individuals with insomnia disorder. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Treatment for Insomnia during Pregnancy; URL: https://clinicaltrials.gov/ct2/show/NCT01846585; Identifier: NCT01846585. CITATION Badon SE, Dietch R, Simpson N, Lyell DJ, Manber R. Daytime napping and nighttime sleep in pregnant individuals with insomnia disorder. J Clin Sleep Med. 2023;19(2):371-377.
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Affiliation(s)
- Sylvia E. Badon
- Kaiser Permanente Northern California Division of Research, Oakland, California
| | | | - Norah Simpson
- Stanford University School of Medicine, Stanford, California
| | | | - Rachel Manber
- Stanford University School of Medicine, Stanford, California
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Ribeiro A, Gabriel R, Garcia B, Cuccio C, Aqeel W, Moreno A, Landeen C, Hurley A, Kavey N, Pfaff D. Temporal relations between peripheral and central arousals in good and poor sleepers. Proc Natl Acad Sci U S A 2022; 119:e2201143119. [PMID: 35696573 PMCID: PMC9231500 DOI: 10.1073/pnas.2201143119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/12/2022] [Indexed: 12/15/2022] Open
Abstract
Good sleepers and patients with insomnia symptoms (poor sleepers) were tracked with two measures of arousal; conventional polysomnography (PSG) for electroencephalogram (EEG) assessed cortical arousals, and a peripheral arterial tonometry device was used for the detection of peripheral nervous system (PNS) arousals associated with vasoconstrictions. The relationship between central (cortical) and peripheral (autonomic) arousals was examined by evaluating their close temporal dynamics. Cortical arousals almost invariably were preceded and followed by peripheral activations, while large peripheral autonomic arousals were followed by cortical arousals only half of the time. The temporal contiguity of these two types of arousals was altered in poor sleepers, and poor sleepers displayed a higher number of cortical and peripheral arousals compared with good sleepers. Given the difference in the number of peripheral autonomic arousals between good and poor sleepers, an evaluation of such arousals could become a means of physiologically distinguishing poor sleepers.
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Affiliation(s)
- Ana Ribeiro
- Laboratory of Neurobiology and Behavior, The Rockefeller University, New York, NY 10065
- Division of Natural Sciences, College of Mount Saint Vincent, New York, NY 10471
| | - Rachel Gabriel
- Division of Natural Sciences, College of Mount Saint Vincent, New York, NY 10471
| | - Bernardo Garcia
- Division of Natural Sciences, College of Mount Saint Vincent, New York, NY 10471
| | - Casey Cuccio
- Division of Natural Sciences, College of Mount Saint Vincent, New York, NY 10471
| | - William Aqeel
- Division of Natural Sciences, College of Mount Saint Vincent, New York, NY 10471
| | - Alejandro Moreno
- Division of Natural Sciences, College of Mount Saint Vincent, New York, NY 10471
| | - Colby Landeen
- Division of Natural Sciences, College of Mount Saint Vincent, New York, NY 10471
| | - Arlene Hurley
- Laboratory of Neurobiology and Behavior, The Rockefeller University, New York, NY 10065
| | - Neil Kavey
- Laboratory of Neurobiology and Behavior, The Rockefeller University, New York, NY 10065
- Department of Psychiatry, Columbia University, New York, NY 10032
| | - Donald Pfaff
- Laboratory of Neurobiology and Behavior, The Rockefeller University, New York, NY 10065
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7
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Pal A, Joshi T, Basu A, Gupta R. Management of Chronic Insomnia Using Cognitive Behavior Therapy for Insomnia (CBT-I) During COVID-19 Pandemic: Does One Shoe Fit All? SLEEP AND VIGILANCE 2022; 6:51-60. [PMID: 35313659 PMCID: PMC8929256 DOI: 10.1007/s41782-022-00197-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/21/2022] [Accepted: 03/05/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE Insomnia is a highly prevalent disorder that is seen across all age groups causing significant morbidity to the patients. Its prevalence has further risen during COVID-19 pandemic. It is widely acknowledged that untreated insomnia can lead to significant health risks and socio-occupational dysfunction. METHODS A narrative review was conducted following focused search of databases. RESULTS Available guidelines mention two different approaches for the management of insomnia-pharmacological and non-pharmacological. Non-pharmacological therapies like multicomponent cognitive behavior therapy for insomnia (CBT-I) have been advocated for the management of acute as well as chronic insomnia in the literature as it has been found efficacious and useful. Multiple variants of CBT-I, e.g., digitally delivered CBT-I, brief CBT-I have been tested during pandemic owing to closure of clinics. However, there are certain issues to be considered while choosing CBT-I as therapy. For example, like other forms of psychotherapies, is there a need for assessing the candidature of patient before administering CBT-I; is CBT-I free of adverse effects as commonly thought; is CBT-I more efficacious than hypnotics; and at last, how to manage cases that are not candidate for CBT-I. CONCLUSION This narrative review addresses the scientific robustness of evidence for issues related to adherence, efficacy and adverse effects of non-pharmacological therapies. Available literature suggests that data related to adherence and efficacy of CBT-I suffer from methodological shortcomings and careful selection of patient is important for the successful therapy. At the same time, attempts have been made to shed light to the areas where CBT-I can be helpful in the management of insomnia.
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Affiliation(s)
- Arghya Pal
- Department of Psychiatry, All India Institute of Medical Sciences, Raibareli, 229405 India
| | - Tanmay Joshi
- Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, 249203 India
| | - Aniruddha Basu
- Department of Psychiatry, All India Institute of Medical Sciences, Kalyani, 741245 India
| | - Ravi Gupta
- Department of Psychiatry and Division of Sleep Medicine, All India Institute of Medical Sciences, Rishikesh, 249203 India
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Lambert-Beaudet F, Journault WG, Rudziavic Provençal A, Bastien CH. Neurofeedback for insomnia: Current state of research. World J Psychiatry 2021; 11:897-914. [PMID: 34733650 PMCID: PMC8546766 DOI: 10.5498/wjp.v11.i10.897] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 05/18/2021] [Accepted: 08/27/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic insomnia affects about 6%-13% of the Canadian population. Although treatments already exist, they each have their own issues. Neurofeedback is a neuromodulation technique that specifically targets abnormal brain activity and is gaining attention as a possible insomnia treatment.
AIM To review the latest studies pertaining to the use of neurofeedback in the treatment of insomnia.
METHODS In this non-systematic review, only experimental studies assessing the effects of neurofeedback on patients with insomnia were targeted across four bibliographic databases.
RESULTS A total of 12 studies were retained. All neurofeedback studies included in this study showed a clear improvement of subjective sleep. However, data concerning objective improvement are contradictory. Most studies regarding surface and z-score neurofeedback show that neurofeedback targeting the sensorimotor rhythm in the sensorimotor cortex may help improve subjective sleep. A placebo effect seems also to be present in some studies. Several limitations were present in each study.
CONCLUSION While studies concerning neurofeedback as a treatment for insomnia are encouraging, many methodological barriers remain to be resolved to prove its efficacy unequivocally. More studies using robust design parameters, as well as the replication of existing studies, are necessary to support neurofeedback as an effective treatment for insomnia.
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Affiliation(s)
| | | | | | - Célyne H Bastien
- Department of Psychology, School of Psychology Laval University, Québec G1V0A6, Canada
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9
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Daytime Neurophysiological Hyperarousal in Chronic Insomnia: A Study of qEEG. J Clin Med 2020; 9:jcm9113425. [PMID: 33114486 PMCID: PMC7694040 DOI: 10.3390/jcm9113425] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/22/2020] [Accepted: 10/22/2020] [Indexed: 11/17/2022] Open
Abstract
Background: The hyperarousal model demonstrates that instability of sleep-wake regulation leads to insomnia symptoms and various neurophysiological hyperarousal states. Previous studies have shown that hyperarousal states that appear in chronic insomnia patients are not limited to sleep at nighttime but are stable characteristics that extend into the daytime. However, this phenomenon is mainly measured at bedtime, so it hard to determine whether it is maintained throughout a 24 h cycle or if it just appears at bedtime. Methods: We examined the resting state qEEG (quantitative electroencephalogram) and ECG (electrocardiogram) of chronic insomnia patients (n = 24) compared to good sleepers (n = 22) during the daytime. Results: As compared with controls, participants with insomnia showed a clearly high beta band activity in eyes closed condition at all brain areas. They showed a low frequency band at the frontal area; high frequency bands at the central and parietal areas were found in eyes open condition. Significantly higher heart rates were also found in the chronic insomnia group. Conclusion: These findings suggest that chronic insomnia patients were in a state of neurophysiological hyperarousal during the middle of the day due to abnormal arousal regulation.
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Hein M, Lanquart JP, Mungo A, Hubain P, Loas G. Impact of number of sleep ultradian cycles on polysomnographic parameters related to REM sleep in major depression: Implications for future sleep research in psychiatry. Psychiatry Res 2020; 285:112818. [PMID: 32035377 DOI: 10.1016/j.psychres.2020.112818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/18/2020] [Accepted: 01/25/2020] [Indexed: 12/22/2022]
Abstract
Given the contradictory data on REMS alterations in major depression, the aim of this study was to empirically demonstrate that based on the number of sleep ultradian cycles, it was possible to highlight different subtypes of major depression characterized by specific patterns of REMS alterations. Demographic and polysomnographic data from 211 individuals (30 healthy controls and 181 untreated major depressed individuals) recruited from the sleep laboratory database were analyzed. Major depressed individuals with sleep ultradian cycles <4 showed alterations consistent with REMS deficiency (non-shortened REM latency as well as decrease in REMS percentage, REMS duration and REMS/NREMS ratio) whereas major depressed individuals with sleep ultradian cycles >4 showed alterations consistent with REMS disinhibition (shortened REM latency as well as increase in REMS percentage, REMS duration and REMS/NREMS ratio). Regarding major depressed individuals with 4 sleep ultradian cycles, their REMS alterations were intermediate to those present in major depressed individuals with sleep ultradian cycles <4 and >4. Thus, in major depressed individuals, the highlighting of this heterogeneity of REMS alterations based on the number of sleep ultradian cycles seems to suggest the involvement of distinct pathophysiological mechanisms and could open new perspectives for future sleep research in psychiatry.
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Affiliation(s)
- Matthieu Hein
- Erasme Hospital, Department of Psychiatry and Sleep Laboratory, Université libre de Bruxelles, ULB, Brussels, Belgium.
| | - Jean-Pol Lanquart
- Erasme Hospital, Department of Psychiatry and Sleep Laboratory, Université libre de Bruxelles, ULB, Brussels, Belgium
| | - Anaïs Mungo
- Erasme Hospital, Department of Psychiatry and Sleep Laboratory, Université libre de Bruxelles, ULB, Brussels, Belgium
| | - Philippe Hubain
- Erasme Hospital, Department of Psychiatry and Sleep Laboratory, Université libre de Bruxelles, ULB, Brussels, Belgium
| | - Gwenolé Loas
- Erasme Hospital, Department of Psychiatry and Sleep Laboratory, Université libre de Bruxelles, ULB, Brussels, Belgium
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11
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Abstract
BACKGROUND Previous literature considers insomnia as one of the features, predictor, and also as a residual symptom of depression. However, chronic insomnia and major depressive disorder (MDD) have overlapping features making differentiation between two difficult. MATERIALS AND METHODS Forty subjects in each of the three categories-MDD, insomnia (I) and combined diagnoses (MDD-I) were recruited in this study after excluding potential confounders. Diagnosis of MDD was made following Diagnostic and Statistical Manual 5 edition (DSM-5), while the International Classification of sleep disorders 3 edition criteria of insomnia were used for diagnosing insomnia. The severity of insomnia and depression was assessed using the Insomnia Severity Index (ISI) and Patient Health Questionnaire-9 (PHQ-9), respectively. Fatigue was assessed using the Fatigue Severity Scale (FSS), which was translated in Hindi for this study. All subjects were also asked regarding effect of good sleep at night on daytime symptoms, especially on mood. RESULTS Subjects in MDD group were younger than the other two. Insomnia group was significantly different from the other two groups on most of the measures according to the DSM-5 criteria for MDD. MDD group had lesser frequencies of initial insomnia, middle insomnia, dissatisfaction with sleep and overall distress during the day. MDD-I group had a higher prevalence of daytime sleepiness and hyperactivity/impulsivity. PHQ-9 score was the lowest in the insomnia group. Despite statistically significantly different, ISI score was clinically comparable. The severity of fatigue was comparable across three groups. Contrary to the MDD group, subjects in insomnia and MDD-I group reported significant improvement in daytime symptoms after a good sleep for even one night. CONCLUSION There is considerable overlap of symptoms between insomnia and MDD. Subjects having insomnia report significant improvement in daytime and mood symptoms after good sleep, contrary to subjects with MDD.
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Affiliation(s)
- Robin Victor
- Department of Psychiatry, Muzaffarnagar Medical College, Muzaffarnagar, Uttar Pradesh, India
| | - Sherry Garg
- Department of Psychiatry, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
| | - Ravi Gupta
- Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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12
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Jang KH, Lee JH, Kim SJ, Kwon HJ. Characteristics of napping in community-dwelling insomnia patients. Sleep Med 2018; 45:49-54. [PMID: 29680428 DOI: 10.1016/j.sleep.2017.12.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/13/2017] [Accepted: 12/30/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We aimed to determine napping characteristics of community-dwelling patients with insomnia disorder (ID) compared to characteristics of normal controls (NC), and to examine the effect of napping on nocturnal sleep. METHODS Adult volunteers who were more than 18 years old were recruited from three rural public health centers in Korea. Data from actigraphy recording and a sleep diary filled out for seven days were obtained. Finally, 115 ID patients and 80 NC subjects were included in this study. Parameters and timing of nocturnal sleep and nap were compared between the ID and NC groups. Two-way analysis of covariance (ANCOVA) was performed to determine the effect of ID diagnosis and napping on sleep parameters. RESULTS Sleep efficiency (SE) in the ID group was significantly lower (p = 0.010), and wake time after sleep onset (WASO) was significantly greater (p = 0.023), compared to the NC group. There was no significant difference in nocturnal sleep or nap timing between the two groups. Nap frequency in the ID group was significantly higher than that in the NC group (p = 0.025). Although ID diagnosis and napping had no independent effect on fragmentation index, their interaction had a significant effect on fragmentation index (p = 0.021). Nap frequency was positively correlated with PSQI score (r = 0.166, p = 0.033). CONCLUSION Insomnia patients showed no significant difference in nap timing or nap duration compared to NC subjects. However, insomnia patients showed higher nap frequency. Frequent napping was associated with poorer subjective sleep quality. Therefore, although napping might not have a negative impact on nocturnal sleep maintenance in NC subjects, it did have an effect on nocturnal sleep in insomnia patients.
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Affiliation(s)
- Kwang Ho Jang
- Department of Psychiatry, Chuncheon National Hospital, Chuncheon, South Korea
| | - Jung Hie Lee
- Department of Psychiatry, Kangwon National University School of Medicine, Chuncheon, South Korea; Department of Psychiatry, Kangwon National University Hospital, Chuncheon, South Korea.
| | - Seong Jae Kim
- Department of Psychiatry, Doeun Hospital, Jincheon, South Korea
| | - Hyo Jeong Kwon
- Department of Psychiatry, Kangwon National University Hospital, Chuncheon, South Korea
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13
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Walsh CM, Ruoff L, Walker K, Emery A, Varbel J, Karageorgiou E, Luong PN, Mance I, Heuer HW, Boxer AL, Grinberg LT, Kramer JH, Miller BL, Neylan TC. Sleepless Night and Day, the Plight of Progressive Supranuclear Palsy. Sleep 2018; 40:4348484. [PMID: 29029214 DOI: 10.1093/sleep/zsx154] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Objectives To elucidate the unique sleep and waking characteristics in progressive supranuclear palsy (PSP), a neurodegenerative disease associated with motor deficits and dementia that largely affects the brainstem and thalamic regions. Methods A total of 20 PSP and 16 healthy older adult controls participated in this study. The participants underwent an overnight polysomnography and multiple sleep latency test (MSLT) the following day. Prior to the MSLT last trial, they were asked to complete the Stanford Sleepiness Scale. Data were assessed for measures of latency to sleep onset, sleep duration, waking, and sleep staging during the night. Mean sleep latency, a measure of daytime sleepiness, sleep onset rapid eye movement (REM) periods, and microsleeps were studied with the MSLT. Spectral analysis of wake electroencephalogram (EEG) was performed for 30-second periods at the start of each MSLT trial. Results PSP took significantly longer time to fall asleep (p < .001), slept less during the night (p ≤ .001), and had more wake after sleep onset than controls (p ≤ .001). PSP had less N2 sleep (p < .05) and N3 sleep (p < .05), and REM sleep (p < .001) than controls. During the MSLT, PSP took significantly longer to fall asleep (p < .001), did not have microsleeps when they remained awake throughout the assessment periods, but were subjectively sleepier than controls (p < .05). Gamma power was increased during wake EEG in PSP (p < .01). Conclusions Sleep/waking regulation and REM sleep regulation are disrupted in PSP, leading to profound sleep deprivation without recuperation. Our findings suggest a diminished homeostatic sleep drive in PSP. This hyperaroused state is unique and is a severely disabling feature of PSP.
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Affiliation(s)
- Christine M Walsh
- Department of Neurology, Memory and Aging Center, University of California San Francisco, 675 Nelson Rising Lane, Suite 190, San Francisco, CA 94158
| | - Leslie Ruoff
- Department of Mental Health, Stress and Health Research Program, San Francisco VA Medical Center, 4150 Clement Street 116P Building 8, San Francisco, CA 94121
| | - Kathleen Walker
- Department of Neurology, Memory and Aging Center, University of California San Francisco, 675 Nelson Rising Lane, Suite 190, San Francisco, CA 94158
| | - Alaisa Emery
- Department of Neurology, Memory and Aging Center, University of California San Francisco, 675 Nelson Rising Lane, Suite 190, San Francisco, CA 94158.,Department of Mental Health, Stress and Health Research Program, San Francisco VA Medical Center, 4150 Clement Street 116P Building 8, San Francisco, CA 94121
| | - Jonathan Varbel
- Department of Mental Health, Stress and Health Research Program, San Francisco VA Medical Center, 4150 Clement Street 116P Building 8, San Francisco, CA 94121
| | - Elissaios Karageorgiou
- Department of Neurology, Memory and Aging Center, University of California San Francisco, 675 Nelson Rising Lane, Suite 190, San Francisco, CA 94158.,Neurological Institute of Athens, Athens, Greece
| | - Phi N Luong
- Department of Neurology, Memory and Aging Center, University of California San Francisco, 675 Nelson Rising Lane, Suite 190, San Francisco, CA 94158
| | - Irida Mance
- Department of Neurology, Memory and Aging Center, University of California San Francisco, 675 Nelson Rising Lane, Suite 190, San Francisco, CA 94158
| | - Hilary W Heuer
- Department of Neurology, Memory and Aging Center, University of California San Francisco, 675 Nelson Rising Lane, Suite 190, San Francisco, CA 94158
| | - Adam L Boxer
- Department of Neurology, Memory and Aging Center, University of California San Francisco, 675 Nelson Rising Lane, Suite 190, San Francisco, CA 94158
| | - Lea T Grinberg
- Department of Neurology, Memory and Aging Center, University of California San Francisco, 675 Nelson Rising Lane, Suite 190, San Francisco, CA 94158.,Department of Pathology, LIM-22, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Joel H Kramer
- Department of Neurology, Memory and Aging Center, University of California San Francisco, 675 Nelson Rising Lane, Suite 190, San Francisco, CA 94158.,Department of Psychiatry, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA 94143
| | - Bruce L Miller
- Department of Neurology, Memory and Aging Center, University of California San Francisco, 675 Nelson Rising Lane, Suite 190, San Francisco, CA 94158
| | - Thomas C Neylan
- Department of Mental Health, Stress and Health Research Program, San Francisco VA Medical Center, 4150 Clement Street 116P Building 8, San Francisco, CA 94121.,Department of Psychiatry, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA 94143
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14
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Role of Sleep Aids and Wake-Promoting Agents During Cognitive Behavior Therapy for Insomnia. CURRENT SLEEP MEDICINE REPORTS 2017. [DOI: 10.1007/s40675-017-0095-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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Hein M, Lanquart JP, Loas G, Hubain P, Linkowski P. Similar polysomnographic pattern in primary insomnia and major depression with objective insomnia: a sign of common pathophysiology? BMC Psychiatry 2017; 17:273. [PMID: 28754103 PMCID: PMC5534116 DOI: 10.1186/s12888-017-1438-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 07/20/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Our aim is to verify empirically the existence of a major depressed subgroup with a similar polysomnographic pattern as primary insomnia, including at rapid eye movement sleep level. METHODS The polysomnographic data from 209 untreated individuals (30 normative, 84 primary insomnia sufferers, and 95 major depressed patients with objective insomnia) who were recruited retrospectively from the Erasme hospital database were studied for the whole night and thirds of the night. RESULTS Primary insomnia sufferers and major depressed patients with objective insomnia exhibit a similar polysomnographic pattern both for the whole night (excess of wake after sleep onset, deficit in slow-wave sleep/rapid eye movement sleep, and non-shortened rapid eye movement latency) and thirds of the night (excess of wake after sleep onset at first and last third, deficit in slow-wave sleep in first third, and deficit in rapid eye movement sleep in first and last third), including at rapid eye movement sleep level. CONCLUSION In our study, we demonstrated that major depressed patients with objective insomnia showed a similar polysomnographic pattern as primary insomnia, including at rapid eye movement sleep level, which supports the hypothesis of a common pathophysiology that could be hyperarousal. This opens new avenues for understanding the pathophysiology of major depression with objective insomnia.
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Affiliation(s)
- Matthieu Hein
- Department of Psychiatry and Sleep Laboratory, Erasme Hospital, Université Libre de Bruxelles, ULB, Brussels, Belgium
- Department of Psychiatry and Sleep Laboratory, Brussels, Belgium
- Route de Lennik, 808-1070, Anderlecht, Belgium
| | - Jean-Pol Lanquart
- Department of Psychiatry and Sleep Laboratory, Erasme Hospital, Université Libre de Bruxelles, ULB, Brussels, Belgium
- Department of Psychiatry and Sleep Laboratory, Brussels, Belgium
| | - Gwénolé Loas
- Department of Psychiatry and Sleep Laboratory, Erasme Hospital, Université Libre de Bruxelles, ULB, Brussels, Belgium
- Department of Psychiatry and Sleep Laboratory, Brussels, Belgium
| | - Philippe Hubain
- Department of Psychiatry and Sleep Laboratory, Erasme Hospital, Université Libre de Bruxelles, ULB, Brussels, Belgium
- Department of Psychiatry and Sleep Laboratory, Brussels, Belgium
| | - Paul Linkowski
- Department of Psychiatry and Sleep Laboratory, Erasme Hospital, Université Libre de Bruxelles, ULB, Brussels, Belgium
- Department of Psychiatry and Sleep Laboratory, Brussels, Belgium
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16
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Hein M, Senterre C, Lanquart JP, Montana X, Loas G, Linkowski P, Hubain P. Hyperarousal during sleep in untreated primary insomnia sufferers: A polysomnographic study. Psychiatry Res 2017; 253:71-78. [PMID: 28364590 DOI: 10.1016/j.psychres.2017.03.045] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 03/22/2017] [Accepted: 03/22/2017] [Indexed: 01/28/2023]
Abstract
Because some evidence favors the hyperarousal model of insomnia, we sought to learn more about the dynamics of this phenomenon during sleep. Polysomnographic data from 30 normative subjects and 86 untreated primary insomnia sufferers recruited from the database of the sleep laboratory were studied for whole nights and in terms of thirds of the night. Untreated primary insomnia sufferers had an increased sleep latency and excess of WASO, together with a deficit in REM and NREM sleep during the entire night. In terms of thirds of the night, they presented a major excess of WASO during the first and last thirds of the night but an excess of lesser importance during the middle third. A deficit in SWS was found during the first third of the night, but for REM, the deficit was present during both the first and last thirds. Primary insomnia sufferers had no SWS or REM deficit during the second third of the night. We found that the hyperarousal phenomenon occurs mainly during the sleep-onset period of the first and last thirds of the night and is less important during the middle third. These results open new avenues for understanding the pathophysiology of primary insomnia.
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Affiliation(s)
- Matthieu Hein
- Erasme Hospital, Free University of Brussels, Department of Psychiatry and Sleep Laboratory, Brussels, Belgium.
| | - Christelle Senterre
- School of Public Health SPU-ESP, Free University of Brussels, Department of Biostatistics, Brussels, Belgium
| | - Jean-Pol Lanquart
- Erasme Hospital, Free University of Brussels, Department of Psychiatry and Sleep Laboratory, Brussels, Belgium
| | - Xavier Montana
- Erasme Hospital, Free University of Brussels, Department of Psychiatry and Sleep Laboratory, Brussels, Belgium
| | - Gwénolé Loas
- Erasme Hospital, Free University of Brussels, Department of Psychiatry and Sleep Laboratory, Brussels, Belgium
| | - Paul Linkowski
- Erasme Hospital, Free University of Brussels, Department of Psychiatry and Sleep Laboratory, Brussels, Belgium
| | - Philippe Hubain
- Erasme Hospital, Free University of Brussels, Department of Psychiatry and Sleep Laboratory, Brussels, Belgium
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17
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Garcia-Rill E, Luster B, D'Onofrio S, Mahaffey S, Bisagno V, Urbano FJ. Implications of gamma band activity in the pedunculopontine nucleus. J Neural Transm (Vienna) 2016; 123:655-665. [PMID: 26597124 PMCID: PMC4877293 DOI: 10.1007/s00702-015-1485-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 11/10/2015] [Indexed: 01/07/2023]
Abstract
The fact that the pedunculopontine nucleus (PPN) is part of the reticular activating system places it in a unique position to modulate sensory input and fight-or-flight responses. Arousing stimuli simultaneously activate ascending projections of the PPN to the intralaminar thalamus to trigger cortical high-frequency activity and arousal, as well as descending projections to reticulospinal systems to alter posture and locomotion. As such, the PPN has become a target for deep brain stimulation for the treatment of Parkinson's disease, modulating gait, posture, and higher functions. This article describes the latest discoveries on PPN physiology and the role of the PPN in a number of disorders. It has now been determined that high-frequency activity during waking and REM sleep is controlled by two different intracellular pathways and two calcium channels in PPN cells. Moreover, there are three different PPN cell types that have one or both calcium channels and may be active during waking only, REM sleep only, or both. Based on the new discoveries, novel mechanisms are proposed for insomnia as a waking disorder. In addition, neuronal calcium sensor protein-1 (NCS-1), which is over expressed in schizophrenia and bipolar disorder, may be responsible for the dysregulation in gamma band activity in at least some patients with these diseases. Recent results suggest that NCS-1 modulates PPN gamma band activity and that lithium acts to reduce the effects of over expressed NCS-1, accounting for its effectiveness in bipolar disorder.
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Affiliation(s)
- E Garcia-Rill
- Center for Translational Neuroscience, Department of Neurobiology and Developmental Sciences, University of Arkansas for Medical Sciences, Slot 847, 4301 West Markham St., Little Rock, AR, 72205, USA.
| | - B Luster
- Center for Translational Neuroscience, Department of Neurobiology and Developmental Sciences, University of Arkansas for Medical Sciences, Slot 847, 4301 West Markham St., Little Rock, AR, 72205, USA
| | - S D'Onofrio
- Center for Translational Neuroscience, Department of Neurobiology and Developmental Sciences, University of Arkansas for Medical Sciences, Slot 847, 4301 West Markham St., Little Rock, AR, 72205, USA
| | - S Mahaffey
- Center for Translational Neuroscience, Department of Neurobiology and Developmental Sciences, University of Arkansas for Medical Sciences, Slot 847, 4301 West Markham St., Little Rock, AR, 72205, USA
| | - V Bisagno
- IFIBYNE-CONICET, ININFA-CONICET, University of Buenos Aires, Buenos Aires, Argentina
| | - F J Urbano
- IFIBYNE-CONICET, ININFA-CONICET, University of Buenos Aires, Buenos Aires, Argentina
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18
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Pérusse AD, Pedneault-Drolet M, Rancourt C, Turcotte I, St-Jean G, Bastien CH. REM sleep as a potential indicator of hyperarousal in psychophysiological and paradoxical insomnia sufferers. Int J Psychophysiol 2015; 95:372-8. [PMID: 25596383 DOI: 10.1016/j.ijpsycho.2015.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 11/30/2014] [Accepted: 01/09/2015] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVES The objective was to study REM sleep macrostructure and microstructure as potential indicators of hyperarousal in insomnia by comparing good sleepers (GS) and insomnia sufferers (INS) (subdivided into psychophysiological "PSY-I" and paradoxical "PARA-I"). DESIGN Cross-sectional comparisons of GS, PSY-I and PARA-I. SETTING Participants slept for 4 consecutive nights in the laboratory where PSG was recorded. Nights 2 and 3 were combined to compare REM sleep between groups. PARTICIPANTS Thirty-nine PSY-I, 27 PARA-I and 47 GS completed the study, comprising home questionnaires, clinical interviews and night PSG recordings. All participants were aged between 25 and 55 and met inclusion criteria for either PSY-I, PARA-I or GS. INTERVENTIONS N/A MEASUREMENTS AND RESULTS Results showed no between group differences on REM sleep macrostructure. As for REM sleep microstructure, PSY-I had an increased number of wake intrusions compared to PARA-I (p=.03). Subjective SE, TST and TWT were significantly correlated with the duration of REM sleep (REMD; p≤.002) and with the proportion of REM sleep for PARA-I (p≤.06). CONCLUSIONS REM sleep macrostructure does not seem to be an adequate indicator of hyperarousal in insomnia. However, the number of wake intrusions in REM could be used to differentiate PSY-I from PARA-I and could reflect the heightened arousal of the former group. Relationships between REM sleep duration and proportion could be linked to dream imagery activity, especially in PARA-I. Further investigations are needed to identify variables that could reflect hyperarousal and differentiate insomnia types.
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Affiliation(s)
- Alexandra D Pérusse
- École de psychologie, 2325 rue des Bibliothèques, Université Laval, Québec, QC, G1V 0A6, Canada; Laboratoire de sommeil et potentiels évoqués cognitifs, 2525 chemin de la Canardière, Centre de recherche de l'Institut universitaire en santé mentale de Québec, Québec, QC,G1J 2G2, Canada.
| | - Maude Pedneault-Drolet
- École de psychologie, 2325 rue des Bibliothèques, Université Laval, Québec, QC, G1V 0A6, Canada; Laboratoire de sommeil et potentiels évoqués cognitifs, 2525 chemin de la Canardière, Centre de recherche de l'Institut universitaire en santé mentale de Québec, Québec, QC,G1J 2G2, Canada.
| | - Christine Rancourt
- École de psychologie, 2325 rue des Bibliothèques, Université Laval, Québec, QC, G1V 0A6, Canada; Laboratoire de sommeil et potentiels évoqués cognitifs, 2525 chemin de la Canardière, Centre de recherche de l'Institut universitaire en santé mentale de Québec, Québec, QC,G1J 2G2, Canada.
| | - Isabelle Turcotte
- École de psychologie, 2325 rue des Bibliothèques, Université Laval, Québec, QC, G1V 0A6, Canada; Laboratoire de sommeil et potentiels évoqués cognitifs, 2525 chemin de la Canardière, Centre de recherche de l'Institut universitaire en santé mentale de Québec, Québec, QC,G1J 2G2, Canada.
| | - Geneviève St-Jean
- École de psychologie, 2325 rue des Bibliothèques, Université Laval, Québec, QC, G1V 0A6, Canada; Laboratoire de sommeil et potentiels évoqués cognitifs, 2525 chemin de la Canardière, Centre de recherche de l'Institut universitaire en santé mentale de Québec, Québec, QC,G1J 2G2, Canada.
| | - Célyne H Bastien
- École de psychologie, 2325 rue des Bibliothèques, Université Laval, Québec, QC, G1V 0A6, Canada; Laboratoire de sommeil et potentiels évoqués cognitifs, 2525 chemin de la Canardière, Centre de recherche de l'Institut universitaire en santé mentale de Québec, Québec, QC,G1J 2G2, Canada.
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Gupta R, Zalai D, Spence DW, BaHammam AS, Ramasubramanian C, Monti JM, Pandi-Perumal SR. When insomnia is not just insomnia: the deeper correlates of disturbed sleep with reference to DSM-5. Asian J Psychiatr 2014; 12:23-30. [PMID: 25441304 DOI: 10.1016/j.ajp.2014.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 08/24/2014] [Accepted: 09/07/2014] [Indexed: 10/24/2022]
Abstract
Recent scientific evidences have brought a paradigm shift in our approach towards the concepts of insomnia and its management. The differentiation between primary and secondary insomnia was proved more hypothetical than actual and based upon the current evidences insomnia subtypes described in earlier system have been lumped into one-insomnia disorder. Research in this field suggests that insomnia occurring during psychiatric or medical disorders has a bidirectional and interactive relationship with and coexisting medical and psychiatric illnesses. The new approach looks to coexist psychiatric or medical disorders as comorbid conditions and hence specifies two coexisting conditions. Therefore, the management and treatment plans should address both the conditions. A number of sleep disorders may present with insomnia like symptoms and these disorders should be treated efficiently in order to alleviate insomnia symptoms. In such cases, a thorough history from the patient and his/her bed-partner is warranted. Moreover, some patients may need polysomnography or other diagnostic tests like actigraphy to confirm the diagnosis of the underlying sleep disorder. DSM-5 classification system of sleep–wake disorders has several advantages, e.g., it has seen insomnia across different dimensions to make it clinically more useful; it focuses on the assessment of severity and guides the mental health professional when to refer a patient of insomnia to a sleep specialist; lastly, it may encourage the psychiatrists to opt for sleep medicine as a career.
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Affiliation(s)
- Ravi Gupta
- Department of Psychiatry & Sleep Clinic, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Doiwala, Dehradun 248140, India.
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20
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Bastien C, Ceklic T, St-Hilaire P, Desmarais F, Pérusse A, Lefrançois J, Pedneault-Drolet M. Insomnia and sleep misperception. ACTA ACUST UNITED AC 2014; 62:241-51. [DOI: 10.1016/j.patbio.2014.07.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 07/09/2014] [Indexed: 11/29/2022]
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