Ecological Momentary Assessment in Primary Insomnia Ecological Momentary Assessment Conference...
-
Upload
noah-porter -
Category
Documents
-
view
215 -
download
0
Transcript of Ecological Momentary Assessment in Primary Insomnia Ecological Momentary Assessment Conference...
Ecological Momentary Assessment Ecological Momentary Assessment in Primary Insomnia in Primary Insomnia
Ecological Momentary Assessment ConferencePittsburgh, PAJuly 10, 2006
Daniel J. Buysse, M.D.Daniel J. Buysse, M.D.
Professor of PsychiatryProfessor of Psychiatry
University of Pittsburgh School of MedicineUniversity of Pittsburgh School of Medicine
Research diagnostic criteria for insomnia Research diagnostic criteria for insomnia disorderdisorder Edinger, Edinger, SLEEPSLEEP 2004; 27:1567-96 2004; 27:1567-96
A.A. The individual reports one or more of the following The individual reports one or more of the following sleep related complaints:sleep related complaints:
1.1. difficulty initiating sleepdifficulty initiating sleep
2.2. difficulty maintaining sleepdifficulty maintaining sleep
3.3. waking up too early, or waking up too early, or
4.4. sleep that is chronically nonrestorative or poor in qualitysleep that is chronically nonrestorative or poor in quality
B.B. The above sleep difficulty occurs despite adequate The above sleep difficulty occurs despite adequate opportunity and circumstances for sleep.opportunity and circumstances for sleep.
Research diagnostic criteria for insomnia Research diagnostic criteria for insomnia disorderdisorder Edinger, Edinger, SLEEPSLEEP 2004; 27:1567-96 2004; 27:1567-96
C.C. At least one of the following forms of daytime At least one of the following forms of daytime impairment related to the nighttime sleep impairment related to the nighttime sleep difficulty is reported by the individual:difficulty is reported by the individual:
1.1. Fatigue/ malaise;Fatigue/ malaise;
2.2. Attention, concentration, or memory impairment;Attention, concentration, or memory impairment;
3.3. Social/ vocational dysfunction or poor school performance;Social/ vocational dysfunction or poor school performance;
4.4. Mood disturbance/ irritability;Mood disturbance/ irritability;
5.5. Daytime sleepiness;Daytime sleepiness;
6.6. Motivation/energy/initiative reduction;Motivation/energy/initiative reduction;
7.7. Proneness for errors/accident at work or while driving;Proneness for errors/accident at work or while driving;
8.8. Tension headaches, and/or GI symptoms in response to Tension headaches, and/or GI symptoms in response to sleep loss;sleep loss;
9.9. Concerns or worries about sleep.Concerns or worries about sleep.
Consequences of insomnia Buysse, Primary Psychiatry, 2005;12(8):50-57
Decreased quality of life Decreased quality of life
Difficulty concentratingDifficulty concentrating
Memory problemsMemory problems
Increased absenteeismIncreased absenteeism
Decreased job performanceDecreased job performance
Increased incidence of psychiatric disorders,Increased incidence of psychiatric disorders,pain, poor healthpain, poor health
Increased risk of falls and hip fracturesIncreased risk of falls and hip fractures
Increased healthcare utilizationIncreased healthcare utilization
Ecological momentary Ecological momentary assessment of assessment of daytime symptoms in daytime symptoms in insomniainsomnia EcologicalEcological: Subjects : Subjects
studied in the environment studied in the environment they typically inhabitthey typically inhabit
MomentaryMomentary: Data : Data collection in near-collection in near-immediate state avoids immediate state avoids retrospective biasretrospective bias
AssessmentAssessment: Multiple : Multiple assessments per day assessments per day allow representative allow representative characterization of characterization of phenomena under study phenomena under study and permit assessment of and permit assessment of temporal variationtemporal variation
Examples of EMA for one week in insomnia patients
Concentration Mood Energy Alertness Overall
Day number
Ra
tin
g
GoalsGoals
Characterize waking symptoms in subjects with Characterize waking symptoms in subjects with Primary Insomnia (PI), using statistical Primary Insomnia (PI), using statistical techniques to analyze EMA datatechniques to analyze EMA data
Compare PI and Good Sleeper Controls (GSC)Compare PI and Good Sleeper Controls (GSC) Compare PI and GSC on “standard” Compare PI and GSC on “standard”
retrospective clinical scales and sleep diaryretrospective clinical scales and sleep diary Examine relationships between EMA ratings, Examine relationships between EMA ratings,
standard scales, sleep diarystandard scales, sleep diary
SubjectsSubjects
GeneralGeneral PI and GSC, 3:1 ratioPI and GSC, 3:1 ratio Age 20-50 years, men and womenAge 20-50 years, men and women Medical history, psychiatric history (SCID), sleep disorders Medical history, psychiatric history (SCID), sleep disorders
history, screening PSG (AHI, PLMAI < 15)history, screening PSG (AHI, PLMAI < 15)
PI (n = 47)PI (n = 47) DSM-IV Primary InsomniaDSM-IV Primary Insomnia PSQI PSQI ≥ 7≥ 7 No specific quantitative criteriaNo specific quantitative criteria
GSC (n = 18)GSC (n = 18) No sleep disorderNo sleep disorder PSQI ≤ 5PSQI ≤ 5
MeasuresMeasures
Retrospective questionnairesRetrospective questionnaires Inventory of Depressive Symptomatology (IDS) – Inventory of Depressive Symptomatology (IDS) –
sleep itemssleep items Beck Anxiety Inventory (BAI)Beck Anxiety Inventory (BAI) Penn State Worry Questionnaire (PSWQ)Penn State Worry Questionnaire (PSWQ) Hyperarousal Scale (HAS)Hyperarousal Scale (HAS) Multidimensional Fatigue Inventory (MFI), general Multidimensional Fatigue Inventory (MFI), general
fatiguefatigue Pittsburgh Sleep Quality Inventory (PSQI)Pittsburgh Sleep Quality Inventory (PSQI) Epworth Sleepiness Scale (ESS)Epworth Sleepiness Scale (ESS)
MeasuresMeasures
Pittsburgh Sleep Diary (PghSD)Pittsburgh Sleep Diary (PghSD) Total sleep timeTotal sleep time Sleep latencySleep latency Wake after sleep onsetWake after sleep onset Sleep efficiencySleep efficiency
Daytime Insomnia Symptom Scale (DISS)Daytime Insomnia Symptom Scale (DISS) 20 visual analog scales20 visual analog scales Presented 4 times per day: Wake up, noon, 6 p.m., Presented 4 times per day: Wake up, noon, 6 p.m.,
bed timebed time Presented on personal data assistantPresented on personal data assistant
StatisticsStatistics
Wilcoxon rank-sum test for retrospective, diary, Wilcoxon rank-sum test for retrospective, diary, and DISS dataand DISS data
Spearman rank-order correlationsSpearman rank-order correlations Functional principal components analysis Functional principal components analysis
(FPCA) for DISS data(FPCA) for DISS data Individual subjects’ data smoothed over time with Individual subjects’ data smoothed over time with
mixed-model B-spline regressions (3 quadratic B-mixed-model B-spline regressions (3 quadratic B-spline functions with equally-spaced knots)spline functions with equally-spaced knots)
FPCAFPCA Varimax rotationVarimax rotation
Functional principal component loading values Functional principal component loading values for items on the daytime symptoms in insomnia for items on the daytime symptoms in insomnia (DISS) scale in primary insomnia subjects(DISS) scale in primary insomnia subjects
Alert CognitionAlert Cognition
ForgetfulForgetful -0.792-0.792
Clear-headedClear-headed 0.7420.742
ConcentrateConcentrate 0.7420.742
EffortEffort -0.677-0.677
AlertAlert 0.4570.457
Positive MoodPositive Mood
RelaxedRelaxed 0.8080.808
EnergeticEnergetic 0.7060.706
CalmCalm 0.6870.687
HappyHappy 0.6580.658
EfficientEfficient 0.4270.427
Negative MoodNegative Mood
AnxiousAnxious 0.7500.750
StressedStressed 0.7030.703
TenseTense 0.6980.698
SadSad 0.6960.696
IrritableIrritable 0.5810.581
Sleepiness/FatigueSleepiness/Fatigue
FatiguedFatigued 0.9480.948
SleepySleepy 0.8800.880
ExhaustedExhausted 0.8410.841
Functional principal components analysis Functional principal components analysis of time series self-report dataof time series self-report data
- - - - Primary Insomnia (n=47) Good Sleeper Controls (n=18)
*p<.001 for each
Alert Cognition Negative Mood
Sleepiness/FatiguePositive Mood
Correlations between DISS factor scores, Correlations between DISS factor scores, retrospective psychological scales, and self-retrospective psychological scales, and self-report sleep measures in insomnia patients report sleep measures in insomnia patients (n=47)(n=47)
MeasureMeasure Alert Alert cognitioncognition
Negative Negative moodmood
Positive Positive moodmood
Sleepiness/Sleepiness/fatiguefatigue
Retrospective Retrospective psychological scalespsychological scales
Inventory of Depressive Inventory of Depressive SymptomatologySymptomatology
*-.32*-.32 **.43**.43 *-.30*-.30 .25.25
Multidimensional Fatigue Multidimensional Fatigue InventoryInventory
-.26-.26 .25.25 *-.35*-.35 ***.53***.53
Sleep diarySleep diary
Sleep latency (minutes)Sleep latency (minutes) *-.35*-.35 *.30*.30 -.23-.23 .26.26
Sleep Efficiency (%)Sleep Efficiency (%) .16.16 -.09-.09 *.30*.30 **-.39**-.39
* p<.05 ** p<.01 ***p<.001* p<.05 ** p<.01 ***p<.001
ConclusionsConclusions
EMA scales correspond to commonly-reported EMA scales correspond to commonly-reported waking symptom dimensions in PIwaking symptom dimensions in PI
EMA indicates differences between PI and GSCEMA indicates differences between PI and GSC LevelLevel of symptoms of symptoms Diurnal patternsDiurnal patterns of symptoms of symptoms
May provide clues to pathophysiology of daytime May provide clues to pathophysiology of daytime dysfunction in insomniadysfunction in insomnia
[[1818F] deoxyglucose PET during a.m. and p.m. F] deoxyglucose PET during a.m. and p.m. wakefulness in healthy adultswakefulness in healthy adults Buysse, Buysse, SleepSleep, 2004; 27:1245-54, 2004; 27:1245-54
Midbrain reticularformation/ Raphe
Pontine reticularformation
Posterior hypothalamus
L Locuscoeruleus
R Locuscoeruleus
Correlations between regional glucose Correlations between regional glucose metabolism and DISS factorsmetabolism and DISS factors
A. Alert cognition positive correlations
B. Sleepiness/Fatigue negative correlations
Correlations between regional glucose Correlations between regional glucose metabolism and DISS factorsmetabolism and DISS factors
A. Positive Affect positive correlations
B. Positive Affect positive correlations
C. Negative Affect negative correlations