Highlights from Sleep
Persistence and Change in Symptoms of Insomnia among Adolescents
Robert E. Roberts, PhD1; Catherine Ramsay Roberts, MPH, PhD2; Wenyaw Chan, PhD3
Division of Health Promotion and Behavioral Sciences, School of Public Health, 2Department of Psychiatry and Behavioral Sciences, Medical
School and 3Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX
1
Objective: To estimate the incidence, chronicity, and remission of
symptoms of insomnia and to examine factors associated with the incidence and chronicity of insomnia among adolescents.
Methods: Data were collected using diagnostic interviews and questionnaires from 4175 youths aged 11 to 17 years at baseline, and 3134
of these youths followed-up a year later. Subjects were sampled from
large managed care populations in a metropolitan area of over 4.7 million. Insomnia was assessed by youth-reported DSM-IV symptom criteria.
Results: One year incidence was 13.9% for 1 or more symptoms, 5.5%
for 1 or more symptoms plus daytime fatigue or sleepiness, and 5.3%
for insomnia caseness. Rates of chronicity were 45.8% for 1 or more
symptoms, 34.7% with daytime fatigue or sleepiness, and 22.8% for
insomnia caseness. There were no effects of age, sex, or family in-
come in predicting incidence or chronicity of insomnia. There was a
weak association of both somatic and psychological dysfunction with
risk of future sleep outcomes, with stronger prediction for psychological
dysfunction.
Conclusions: These results document further the public health burden
of insomnia among adolescents. Prevalence of insomnia is comparable
to that of other major psychiatric disorders such as mood, anxiety, disruptive, and substance use disorders. Incidence over one year also is
high. Insomnia represents a chronic condition, further enhancing burden.
Keywords: Adolescents, insomnia, incidence, risk factors, chronicity
Citation: Roberts RE; Roberts CR; Chan W. Persistence and change
in symptoms of insomnia among adolescents. SLEEP 2008;31(2):177184.
Polysomnographic Respiratory Abnormalities in Asymptomatic Individuals
Milena K. Pavlova, MD; Jeanne F. Duffy, MBA, PhD; Steven A. Shea, PhD
Division of Sleep Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
Study objectives: Polysomnographic respiratory abnormalities have
been extensively studied in the general population, but studies have
not targeted completely healthy individuals. We aimed to (1) define the
frequency of respiratory disturbances (RDI: events per hour of sleep)
during sleep in healthy individuals using current techniques and criteria
and (2) determine how these abnormalities change with age and sex.
Design and Setting: Cross-sectional analyses of RDI in healthy volunteers.
Participants: One hundred sixty-three individuals (106 men) were
screened for chronic medical illness, as confirmed by extensive questionnaires, physical examination, electrocardiography, and laboratory
analysis. Obese subjects (body mass index > 30 kg/m2) and subjects
taking medications were excluded.
Interventions, Measurements and Results: Subjects underwent full
polysomnography using current standard recording and scoring techniques. There was a remarkable increase in RDI with age, particularly
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008
over 50 years. Ninety-five percent of currently healthy subjects under 50
years of age had an RDI <15, whereas 50% of subjects older than 65
years had an RDI <15. Men had a higher RDI (median 10) than women
(median 5). The effect of age on RDI was similar in men and women.
Conclusions: RDI increases with age even in healthy individuals without symptoms or signs of obstructive sleep apnea syndrome. We do not
know whether these individuals will develop pathophysiologic consequences over time or whether this increase with age reflects a normal
aging process. If the former, treatment should be considered regardless
of symptoms. If the latter, the criteria for treatment should be adjusted
by age.
Keywords: Sleep apnea, aging, healthy, sleep-disordered breathing,
normal
Citation: Pavlova MK; Duffy JF; Shea SA. Polysomnographic respiratory abnormalities in asymptomatic individuals. SLEEP 2008;31(2):241248.
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Highlights from SLEEP
Comparison of Sleep Parameters from Actigraphy and Polysomnography in
Older Women: The SOF Study
Terri Blackwell, MA1; Susan Redline, MD, MPH2; Sonia Ancoli-Israel, PhD3; Jennifer L. Schneider, MPH1; Susan Surovec, BA2; Nathan L. Johnson, MS2;
Jane A. Cauley, DrPH4; Katie L. Stone, PhD1; for the Study of Osteoporotic Fractures Research Group
California Pacific Medical Center Research Institute, San Francisco, CA; 2Center of Clinical Investigation, Case Western Reserve University,
Cleveland, OH; 3Department of Psychiatry, University of California, San Diego and Veterans Affairs San Diego Healthcare System, San Diego,
CA; 4University of Pittsburgh, Pittsburgh, PA
1
Study Objectives: Total sleep time (TST), sleep efficiency (SE), and
wake after sleep onset (WASO) as assessed by actigraphy gathered
in 3 different modes were compared to polysomnography (PSG) measurements. Each mode was compared to PSG to determine which was
more accurate. Associations of the difference in TST measurement with
demographics and sleep characteristics were examined.
Design: Observational study.
Setting: Community-based.
Participants: Sixty-eight women (mean age 81.9 years) from the latest visit of the Study of Osteoporotic Fractures who were concurrently
measured with PSG and actigraphy.
Interventions: N/A.
Measurements and Results: In-home 12-channel PSG was gathered
along with actigraphy data in 3 modes: proportional integration mode
(PIM), time above threshold (TAT) and zero crossings mode (ZCM). The
PIM mode corresponded better to PSG, with a mean overestimation of
TST of 17.9 min. For the PIM mode, the estimation of TST and SE by
PSG and actigraphy significantly differed (P < 0.01), while the estima-
tion of WASO was similar (P = 0.27). The intraclass correlation between
the 2 procedures was moderate to high (PIM mode: TST 0.76; SE 0.61;
WASO 0.58). On average, the PIM mode underestimated TST by 68
min for those who slept ≤5 hr, overestimated TST by 31 min for those
with SE <70%, and underestimated TST by 24 min for self-reported
poor sleepers (P < 0.05).
Conclusions: Sleep parameters from actigraphy corresponded reasonably well to PSG in this population, with the PIM mode of actigraphy
correlating highest. Those with poor sleep quality had the largest measurement error between the 2 procedures.
Keywords: Actigraphy, polysomnography, total sleep time, sleep efficiency, validation
Citation: Blackwell T; Redline S; Ancoli-Israel S; Schneider JL; Surovec
S; Johnson NL; Cauley JA; Stone KL; for the Study of Osteoporotic
Fractures Research Group. Comparison of sleep parameters from actigraphy and polysomnography in older women: the sof study. SLEEP
2008;31(2):283-291.
High Prevalence of Eating Disorders in Narcolepsy with Cataplexy: A CaseControl Study
Hal A. Droogleever Fortuyn, MD1; Sofie Swinkels, PhD1; Jan Buitelaar, MD, PhD1; Wily O. Renier, MD, PhD2; Joop W. Furer, PhD3; Cees A. Rijnders, MD3,4;
Paul P. Hodiamont, MD, PhD5; Sabastiaan Overeem, MD, PhD2,6
Department of Psychiatry, 2Department of Neurology, 3Department of Social Medicine, Radboud University Nijmegen Medical Center, Nijmegen,
The Netherlands; 4Institute for Mental Health Care, Midden Brabant, Tilburg, The Netherlands; 5Clinical Health Psychology, University of Tilburg,
Tilburg, The Netherlands; 6Center for Sleep-Wake Disorders Kempenhaeghe, Heeze, The Netherlands
1
Study Objectives: To study the prevalence of and symptoms of eating
disorders in patients with narcolepsy.
Design: We performed a case-control study comparing symptoms of
eating disorders in patients with narcolepsy versus healthy population
controls, using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN 2.1). To study whether an increased body mass index (BMI)
could be responsible for symptoms of an eating disorder, we also compared patients with BMI-matched controls, using the SCAN as well as
the Eating Disorder Examination-Questionnaire.
Setting: University hospital.
Patients and participants: Patients with narcolepsy/cataplexy (n = 60)
were recruited from specialized sleep centers. Healthy controls (n =
120) were drawn from a population study previously performed in the
Netherlands. Separately, 32 BMI-matched controls were recruited.
Interventions: N/A.
Measurements and Results: In total, 23.3% of the patients fulfilled the
criteria for a clinical eating disorder, as opposed to none of the control
subjects. Most of these were classified as Eating Disorder—Not Otherwise Specified, with an incomplete form of binge eating disorder. On
the symptom level, half of the patients reported a persistent craving for
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008
food, as well as binge eating. Twenty-five percent of patients even reported binging twice a week or more often. When compared with BMImatched controls, the significant increases persisted in symptoms of
eating disorders among patients with narcolepsy. Except for a higher
level of interference in daily activities due to eating problems in patients
using antidepressants, medication use did not influence our findings.
Conclusions: The majority of patients with narcolepsy experience a
number of symptoms of eating disorders, with an irresistible craving for
food and binge eating as the most prominent features. Eating disorder
symptomatology interfered with daily activities. These findings justify
more attention for eating disorders in the treatment of patients with narcolepsy.
Keywords: narcolepsy, body weight, obesity, eating disorders, binge
eating, bulimia
Citation: Droogleever Fortuyn HA; Swinkels S; Buitelaar J; Renier WO;
Furer JW; Rijnders CA; Hodiamont PP; Overeem S. High prevalence
of eating disorders in narcolepsy with cataplexy: a case-control study.
SLEEP 2008;31(3):335-341.
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Highlights from SLEEP
Sleep in Adults with Attention Deficit Hyperactivity Disorder (ADHD) Before and
During Treatment with Methylphenidate: A Controlled Polysomnographic Study
Esther Sobanski, MD; Michael Schredl, PhD; Nina Kettler, MD; Barbara Alm, MD
Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Mannheim, Germany
Study Objectives: Sleep problems are frequently associated with
childhood ADHD, as indicated by numerous polysomnographic investigations showing increased nocturnal movements, reduced sleep efficiency, and decreased percentage of REM sleep (although findings
are not consistent over all studies). Data on objective and subjective
sleep parameters in adults with ADHD are sparse, and to date the impact of stimulants, the most widely used pharmacological treatment for
ADHD, on sleep in adults with ADHD has not been examined. Thus the
objectives of our study were to assess objective and subjective sleep
parameters in adults with ADHD and the impact of stimulant medication
on sleep.
Design: Two-group comparison and open-label therapy study.
Participants: We enrolled 34 nonmedicated patients with ADHD, of
whom 24 were without current comorbid psychiatric disorders, and 34
sex- and gender-matched control subjects without current psychiatric
disorders or psychotropic medication.
Interventions: Ten patients were treated with methylphenidate over
≥26 days with a mean daily dose of 36.7 ± 11.2 mg.
Measurements: Polysomnographic recording over 2 consecutive
nights as well as assessments of subjective sleep parameters were
performed in all patients and controls before treatment and reassessed
in those patients receiving methylphenidate.
Results: Compared to controls untreated patients showed increased
nocturnal activity, reduced sleep efficiency, more nocturnal awakenings
and reduced percentage of REM sleep. Treatment with methylphenidate resulted in increased sleep efficiency as well as a subjective feeling of improved restorative value of sleep.
Conclusions: Sleep problems in patients with ADHD continue from
childhood to adulthood, with similar objective sleep characteristics in
adults and children with ADHD. Medication with methylphenidate appears to have beneficial effects on sleep parameters in adults with
ADHD.
Keywords: Attention deficit hyperactivity disorder, polysomnography,
sleep, methylphenidate
Citation: Sobanski E; Schredl M; Kettler N; Alm B. Sleep in adults
with attention deficit hyperactivity disorder (adhd) before and during
treatment with methylphenidate: a controlled polysomnographic study.
SLEEP 2007;31(3):375-381.
Cardiovascular Disease and Health-Care Utilization in Snorers: a Population
Survey
Andrea Dunai, MD1; Andras P. Keszei, MD, PhD2; Maria S. Kopp, MD, PhD1; Colin M. Shapiro, MBBCh, PhD, FRCPC3; Istvan Mucsi, MD, PhD1,4,5;
Marta Novak, MD, PhD1,3
Institute of Behavioral Sciences, Faculty of Medicine, Semmelweis University, Budapest, Hungary; 2Samuel Lunenfeld Research Institute,
Mount Sinai Hospital, Toronto, Canada; 3Department of Psychiatry, University Health Network, University of Toronto, Toronto, Canada; 4First
Department of Internal Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary; 5Division of Nephrology, Humber River
Regional Hospital and Faculty of Medicine, University of Toronto, Toronto, Canada
1
Study Objectives: We assessed the prevalence of self-reported snoring in the Hungarian population and established whether different types
of snoring are associated with cardiovascular disorders and increased
health-care utilization.
Design: Cross-sectional study. Door-to-door survey.
Setting: Nationally representative population in Hungary.
Participants: Interviews were carried out in the homes of 12,643 persons. We used the Hungarian National Population Register as the sampling frame and implemented a clustered, stratified sampling procedure.
The study population represented 0.16% of the population over the age
of 18 years according to age, sex, and 150 subregions of the country.
Interventions: Not applicable.
Measurements and Results: Thirty-seven percent of men and 21%
of women reported loud snoring with breathing pauses. Hypertension,
myocardial infarction, and stroke were reported by 26%, 3%, and 4% of
the respondents, respectively. There was a significant increase in the
prevalence of hypertension, myocardial infarction, and stroke in quiet
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008
and loud snorers, as compared with nonsnorers. Multivariate analysis
showed an association between loud snoring and hypertension (odds
ratio [OR]: 1.40, 95% confidence interval [CI]: 1.24 - 1.58), myocardial infarction (OR: 1.34, CI: 1.04 - 1.73), and stroke (OR: 1.67, CI:
1.32 - 2.11) after statistical adjustment for age, sex, body mass index,
diabetes, level of education, smoking, and alcohol consumption. Loud
snoring was also associated with measures of health-care use in both
sexes.
Conclusions: Snoring is frequent in the Hungarian adult population,
and loud snoring with breathing pauses, in contrast with quiet snoring, is associated with an increased risk of cardiovascular disease and
increased health-care utilization.
Keywords: snoring, hypertension, cardiovascular disease, stroke, myocardial infarction, health-care utilization, sleep-disordered breathing
Citation: Dunai A; Keszei AP; Kopp MS; Shapiro CM; Mucsi I; Novak
M. Cardiovascular disease and health-care utilization in snorers: a
population survey. SLEEP 2008;31(3):411-416.
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