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  • Chronic insomnia: clinical and research challenges--an agenda.

    3 July 2018

    Chronic insomnia afflicts up to 10% of the population in Western industrialized countries. It is characterized by delayed sleep onset, problems in maintaining sleep, early morning awakening or the feeling of non-restorative sleep coupled with significant daytime impairments on an emotional, social or professional level. It can occur as a co-morbid condition in any other medical or mental disorder, but also as a primary condition. Within the last decade new diagnostic and differential diagnostic approaches have been suggested that enhance diagnostic precision. Epidemiological data and data relating to the health care and cost situation of chronic insomnia suggest a huge burden for society. Chronic insomnia leads to a clear-cut increased risk for psychopathology (i. e., affective disorders) and probably also for cardiovascular and metabolic dysfunction. The pathophysiology of the condition is still poorly understood and will profit from integrating modern neuroscientific approaches (animal studies, molecular biology, neuroimaging, neurophysiology, etc.). Current treatment strategies are mainly based on cognitive behavioural interventions (CBT-I) and hypnotic treatment with benzodiazepine receptor agonists and sedating antidepressants. Although the effectiveness of these treatments has been clearly demonstrated, a substantial proportion of patients proves to be treatment-resistant or profits only poorly. The question of long-term pharmaceutical treatment of chronic insomnia, at least in Europe, is unresolved and urgently needs answers. Novel rational treatment avenues require clues on causes and mechanisms from integrated neuroscientific approaches. The important issues concerning insomnia treatment in the future especially in Europe will be reviewed and discussed critically.

  • Do sleep difficulties exacerbate deficits in sustained attention following traumatic brain injury?

    3 July 2018

    Sustained attention has been shown to be vulnerable following traumatic brain injury (TBI). Sleep restriction and disturbances have been shown to negatively affect sustained attention. Sleep disorders are common but under-diagnosed after TBI. Thus, it seems possible that sleep disturbances may exacerbate neuropsychological deficits for a proportion of individuals who have sustained a TBI. The aim of this prospective study was to examine whether poor sleepers post-TBI had poorer sustained and general attentional functioning than good sleepers post-TBI. Retrospective subjective, prospective subjective, and objective measures were used to assess participants' sleep. The results showed that the poor sleep group had significantly poorer sustained attention ability than the good sleep group. The differences on other measures of attention were not significant. This study supports the use of measures that capture specific components of attention rather than global measures of attention, and highlights the importance of assessing and treating sleep problems in brain injury rehabilitation.

  • The impact of sleep-related attentional bias on polysomnographically measured sleep in primary insomnia.

    3 July 2018

    STUDY OBJECTIVES: Although sleep-related attentional bias has been shown to be evident in primary insomnia, the association with objectively measured sleep has not been investigated. In the present study, we used polysomnography (PSG) to fill this void. DESIGN: Patients with primary insomnia and healthy controls were studied using a visual dot probe task (VDP) and an emotional Stroop task (EST). Additionally, polysomnography was carried out in a sub-sample (n = 22) of patients in the subsequent night. SETTING: Department of Psychiatry and Psychotherapy of the University of Freiburg Medical Center. PARTICIPANTS: Thirty patients with primary insomnia and 30 matched healthy controls. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Patients with primary insomnia demonstrated a significant sleep-related attentional bias compared to controls in the EST but no significant group effects were found for the VDP. VDP attentional bias scores were positively correlated with measures of sleep pressure, including total sleep time, sleep efficiency, and the amount of slow wave sleep. EST attentional bias scores were not correlated with subsequent PSG parameters, and we did not observe a correlation between attentional bias scores on the two tasks. CONCLUSIONS: The unexpected relationship between increased attentional bias, in the VDP task, and improved markers of sleep duration and continuity, may be indicative of a homeostatic craving for sleep in those with high attentional bias. This awaits further testing in multiple night studies, to shed light on the mechanisms and implications of sleep-related attentional bias.

  • The impact of childhood epilepsy on quality of life: a qualitative investigation using focus group methods to obtain children's perspectives on living with epilepsy.

    3 July 2018

    As children's perceptions of their quality of life are unique, it is essential to elicit their concerns directly rather than from proxy informants. This study therefore aimed to investigate the impact of childhood epilepsy on quality of life directly from the child's perspective. Focus group techniques and qualitative analysis were utilized. Twenty-two children between 7 years 4 months and 12 years 6 months of age (11 females, 11 males) were stratified by age (7-8, 9-10, 11-12 years) into five focus groups. Data were transcribed and analyzed using grounded theory techniques to generate themes and categories. Themes were presented using the children's language. Two major themes were identified, "things to do with growing up" and "things to do with epilepsy," with five and four subthemes, respectively. No significant age-related differences were found. A conceptual model illustrates these findings, and comparisons are made to previous research with adolescents using similar methodology.

  • Development and validation of a measure of the impact of epilepsy on a young person's quality of life: Glasgow epilepsy outcome scale for young persons (GEOS-YP).

    3 July 2018

    OBJECTIVE: The goal of the work described here was to develop and validate a measure of the impact of epilepsy on an adolescent's quality of life that is based on direct exploration of the adolescent's views. METHODS: Initial scale development was based on data generated through qualitative methods (focus groups) in a previous study [McEwan MJ, Espie CA, Metcalfe J, Brodie MJ, Wilson MT. Seizure 2004;13:15-31]. A draft measure was piloted (n=30) and refined using correlational methods. Psychometric properties were established by means of a preliminary field trial (n=78). RESULTS: An initial item pool of 76 was refined to 50. The structure of the measure mirrored the conceptual model derived from focus group study; Part 1 covered issues relating to adolescent development (identity formation) with five subscales, and Part 2 covered epilepsy-related issues with four subscales. The final GEOS-YP had good internal consistency (alpha=0.91) and test-retest reliability (rho=0.75). Concurrent and construct validity was acceptable, and the GEOS-YP discriminated on dimensions of clinical importance. Participant feedback suggested the measure has excellent face validity and potential clinical utility. CONCLUSIONS: The GEOS-YP is a direct measure of how adolescents perceive epilepsy impacts their quality of life. The GEOS-YP has sound psychometric properties and provides a relatively brief and potentially useful clinical outcome tool.

  • Examining the feed forward model of problem drinking and co-morbid panic disorder using a single case approach

    3 July 2018

    Alcohol use and anxiety disorder frequently co-occur. Despite this, no research has satisfactorily examined the effect of alcoholism treatment on anxiety states. The effect of Relapse Prevention (RP) treatment on alcohol dependence and co-morbid panic disorder in a single case was therefore examined. RP reduced alcohol intake and anxiety levels, and eliminated panic attacks, although carrying alcohol to prevent panic attack remained. Belief change was achieved when this behaviour was eliminated. Results are consistent with a "feed-forward" model of co-morbidity. The need for further research exploring RP and co-morbid anxiety disorder is emphasized, as is work examining alcohol-related safety-seeking behaviour.

  • Sensitivity and specificity of measures of the insomnia experience: a comparative study of psychophysiologic insomnia, insomnia associated with mental disorder and good sleepers.

    3 July 2018

    STUDY OBJECTIVES: To explore proposed explanatory mechanisms in psychophysiologic insomnia by investigating the sensitivity and specificity of commonly used insomnia research tools in discriminating psychophysiologic insomnia, insomnia associated with mental disorder, and good sleepers. DESIGN: Cross-sectional, between-group comparison of responses from subjects with psychophysiologic insomnia, those with insomnia associated with mental disorder, and good sleepers to psychometrically robust self-report instruments. SETTING: Attendees at adult community outpatient clinics. PARTICIPANTS: Fifty-four adults (36 women, 18 men; average age 40 years) across 3 groups (n = 18 per group). Participants with psychophysiologic insomnia met combined Inteernational Classification of Sleep Disorders, Revised and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and had no history of mental disorder. Participants with insomnia associated with mental disorder satisfied the same criteria for sleep disturbance and met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (Structured Clinical Interview for DSM-IV axis-I Disorders) criteria for depressive disorder. The majority had comorbid anxiety disorder. Insomnia duration in the groups with psychophysiologic insomnia and insomnia associated with mental disorder was around 10 years. Good sleepers served as a control group and included self-reported good sleepers with no history of sleep problems or psychiatric disorder. INTERVENTION: N/A. MEASUREMENTS AND RESULTS: Analyses of variance, adjusted for multiple comparisons, indicated no between-group differences on a measure of sleep-related stimulus control, and self-reported somatic arousal was higher in subjects with insomnia associated with mental disorder than in good sleepers or those with psychophysiologic insomnia. Subjects with insomnia associated with mental disorder and psychophysiologic insomnia had poorer sleep hygiene and were characterized by heightened mental arousal. Logistic regression indicated that "effortful preoccupation with sleep" discriminated subjects with both psychophysiologic insomnia (100% sensitivity, 94% specificity) and insomnia associated with mental disorder (100%, 100%) from good sleepers and that only depressive symptomatology discriminated insomnia associated with mental disorder from psychophysiologic insomnia. CONCLUSION: Psychophysiologic insomnia and insomnia associated with mental disorder may be on a continuum of insomnia severity, rather than categorically distinct. Insomnia associated with mental disorder may respond to psychological intervention. Factors specifically discriminating insomniacs from good sleepers require further investigation.

  • A systematic review of the contribution of qualitative research to the study of quality of life in children and adolescents with epilepsy.

    3 July 2018

    A sizeable literature focusing on QOL in children and adolescents with epilepsy has been produced over the last few years. However, relatively little emphasis has been placed on defining these issues from direct exploration of children's and adolescents' views. Qualitative methodologies are proposed in this review as an appropriate means of eliciting such information. This review systematically investigated the extent to which studies of QOL in children and adolescents with epilepsy have used recognised qualitative methodology. Articles for inclusion were identified by searching the term 'epilepsy', combined with 'adolescent(s) and/or child(ren)' and 'psychosocial and/or quality of life'. Selected articles were reviewed and rated using CASP Guidelines for qualitative research by two independent raters. Seventeen studies were retrieved through literature search. Of these six used some form of qualitative methodology either individually or combined with quantitative methods. However, only one study met quality criteria for selection in this systematic review. A summary of both selected and excluded studies is presented and methodological limitations discussed. Recommendations for appropriate methodology for investigation of QOL issues in children and adolescents are given.

  • Quality of life and psychosocial development in adolescents with epilepsy: a qualitative investigation using focus group methods.

    3 July 2018

    The majority of previous studies investigating the impact of epilepsy on the QOL of adolescents have used proxy opinions from clinicians and/or parents. This study highlights the need for research to investigate QOL from the direct perspective of adolescents and consider issues in the context of a developmental perspective. A focus group technique was used. Twenty-two adolescents aged between 12 years 4 months and 18 years 0 months (6 males and 16 females) were stratified by age (12-13, 14-15 and 16+ years) into six focus groups. Data were transcribed and QSR NUD*IST 4.0 was used to help generate central themes. Several procedures were undertaken to increase validity and reliability of findings. Analysis identified two main themes comprising (a) issues related to adolescent development (identity formation) and (b) epilepsy related variables, with five and four main sub-themes, respectively ('peer acceptance', 'development of autonomy', 'school related issues', 'epilepsy as part of me' and 'future', and 'medication issues', 'seizures', 'knowledge of epilepsy' and 'sense of uncertainty'). The main issues related to peer acceptance and development of autonomy. In contrast to previous studies, academic difficulties were not highlighted as an issue. No significant age-related differences in issues were identified. A conceptual model representing these findings is presented and clinical implications and suggestions for future research are reported.

  • Glasgow Anxiety Scale for people with an Intellectual Disability (GAS-ID): Development and psychometric properties of a new measure for use with people with mild intellectual disability

    3 July 2018

    Background. Self-rating scales are widely used in general adult practice; however, there is no reliable and valid method for assessing state anxiety in people with intellectual disability (ID). The present study describes the development and psychometric evaluation of a new scale, the Glasgow Anxiety Scale for People with an Intellectual Disability (GAS-ID). Methods. First, an item pool was generated from focus groups, a review of the literature and clinician feedback. Secondly, a draft scale was administered to 19 anxious and 16 non-anxious people with ID for further validation and appraisal of reliability. Thirdly, the scale was completed by 19 anxious, non-ID people for cross-validation with the Beck Anxiety Inventory (BAI). Finally, physiological concomitants were validated by pulse-oximetry. Results. The 27-item GAS-ID discriminated anxious from non-anxious participants, had good test-retest reliability (r=0.95) and internal consistency (α=0.96), and was reasonably correlated with the BAI (ρ=0.75). The correlation between the physiological subscale of the GAS-ID and changes in pulse rate was moderately significant (ρ=0.52). Conclusions. This preliminary study suggests that the GAS-ID offers a psychometrically robust and practical (5-10 min) approach to the appraisal of anxiety in this population.