- Behavioral Sleep Medicine
Clinical Professor, Psychiatry and Behavioral Sciences
Director, Clinical Psychology Fellowship (APA accredited), Department of Psychiatry (2021 - Present)
Director, Clinical Fellowship (SBSM, APA accredited), Sleep Health & Insomnia Program (2017 - Present)
Associate Director, Sleep Health & Insomnia Program (2015 - Present)
Board Certification, Society for Behavioral Sleep Medicine, Behavioral Sleep Medicine (2019)
Board Certification: American Board of Sleep Medicine, Sleep Medicine (2013)
Internship: Warren Alpert Medical School Brown University (2009) RI
PhD Training: University of Pennsylvania (2009) PA
Fellowship: Stanford University Medical Center (2013) CA
T32 Fellowship, Beth Israel Deaconess Medical Center/Harvard Medical School (2011)
Postdoctoral Faculty Sponsor
Sarah Adut, Talhah Alvi, Michael Breske, Kristen Burda, Nicole Carmona, Pattric Davis, Tianwei Du, Jason Grossman, Sam Hayward, Yazmine Huizar, Yehsong Kim, Sharon Maroukel, Julia Rios, Natasha Sidhu, Jeremiah Simmons, Emily Vogel, Sarina Volari
Postdoctoral Research Mentor
Graduate and Fellowship Programs
Perspectives on increasing the impact and reach of CBT-I.
Cognitive behavioral therapy for insomnia is now recognized as the front-line treatment for chronic insomnia, yet many challenges remain in improving its impact and reach. This manuscript describes our perspective on some of these challenges. Based on the literature that maladaptive cognitions predict low adherence and that high levels of cognitive-emotional hyperarousal may be associated with poor outcomes, we propose added focus on cognitive therapy strategies in CBT-I. Specifically, we propose broadening the range of traditional cognitive therapy strategies, utilizing acceptance-based strategies, and fuller integration of the broadened range of cognitive strategies into CBT-I throughout the course of treatment. We also highlight a few other promising emerging approaches to enhance the impact of CBT-I. These include involving partners to promote adherence with CBT-I treatment recommendations, using culturally relevant treatment adaptations to increase retention of patients in treatment, and using strategies for timely identification of barriers to engagement. We propose broadening the public health impact of CBT-I by integrating support for reduction in long-term use of hypnotic sleep medications, which is in line with current medical guidelines. We advocate for a case conceptualization-based approach for implementing CBT-I in a patient-centered manner, flexibly, yet with fidelity, to enhance its impact by addressing the factors above. For increasing the reach of CBT-I, we discuss the need to train more clinicians and ways to combine therapist and digital deliveries of CBT-I, highlighting stepped care strategies.
View details for DOI 10.1093/sleep/zsad168
View details for PubMedID 37903637
Randomized controlled trial of cognitive behavioral therapy for perinatal insomnia: postpartum outcomes.
Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine
This study aimed to assess the effectiveness of cognitive behavioral therapy for insomnia (CBTI) during the postpartum period, as part of a larger randomized controlled trial of CBTI on perinatal insomnia.179 women of 18 to 30 gestational weeks with insomnia disorder were randomized to CBTI or an active control (CTRL) therapy. Participants were assessed between 18-32 weeks of pregnancy at baseline, after the intervention during pregnancy, and at 8, 18, and 30 weeks postpartum. The primary outcome were the Insomnia Severity Index (ISI) and total awake time (TWT), defined as minutes awake during the sleep opportunity period, assessed with actigraphy and sleep diaries. Included in the analyses were women who provided data for at least one of three postpartum assessments (68 in CBTI; 61 in CTRL).Piecewise mixed-effects models revealed a main effect reflecting reduction in ISI scores from 8 to 18 weeks postpartum (p = .036) and a non-significant increase from 18 to 30 weeks; significant effects for group allocation were present only in week 30 (p = .042). CTRL participants reported significantly longer time awake, excluding time spent caring for the infant, at each postpartum assessment; time awake at night caring for the infant did not differ between groups. There was no significant group difference in the postpartum trajectory of actigraphy measured TWT, the two diary measures of time awake (p-values > .05). CBTI participants with at least 50% reduction in ISI during pregnancy had consistently stable ISI scores (mean < 6) during the postpartum period; those in CTRL had variable ISI scores over time with large individual differences.For women with insomnia disorder during pregnancy, CBTI initiated during pregnancy conferred postpartum benefits in terms of wakefulness after sleep onset (excluding time spent caring for the infant) and insomnia severity, though the latter emerged only later in the postpartum period. These findings underscore the importance of treating insomnia during pregnancy, a conclusion that is further supported by our finding that pregnant women who responded to insomnia treatment during pregnancy experienced better sleep in the postpartum period.Clinicaltrials.gov, NCT01846585.
View details for DOI 10.5664/jcsm.10572
View details for PubMedID 37078188
Beliefs about prescription sleep medications and interest in reducing hypnotic use: an examination of middle-aged and older adults with insomnia disorder.
Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine
STUDY OBJECTIVES: To examine beliefs about prescription sleep medications (hypnotics) among individuals with insomnia disorder seeking cognitive behavioral therapy for insomnia (CBTI) and predictors of wishing to reduce use.METHODS: Baseline data was collected from 245 adults 50 years and older enrolled in the "RCT of the effectiveness of stepped-care sleep therapy in general practice (RESTING)" study. T-tests compared characteristics of prescription sleep medication users with those of non-users. Linear regression assessed predictors of patients' beliefs about sleep medication necessity and hypnotic-related concerns. Among users, we examined predictors of wishing to reduce sleep medications, including perceived hypnotic dependence, beliefs about medications, and demographic characteristics.RESULTS: Users endorsed stronger beliefs about the necessity of sleep medications and less concern about potential harms than non-users (p < .01). Stronger dysfunctional sleep-related cognitions predicted greater beliefs about necessity and concern about use (p < .01). Patients wishing to reduce sleep medications reported greater perceived hypnotic dependence than those disinterested in reduction (p < .001). Self-reported dependence severity was the strongest predictor of wishing to reduce use (p = .002).CONCLUSIONS: Despite expressing strong beliefs about necessity, and comparatively less concern about taking sleep medications, three-quarters of users wished to reduce prescription hypnotics. Results may not generalize to individuals with insomnia not seeking non-pharmacological treatments. Upon completion, the RESTING study will provide information about the extent to which therapist-led and digital CBTI contribute to prescription hypnotic reduction.CLINICAL TRIAL REGISTRY: Registry: ClinicalTrials.gov; Name: The RESTING Insomnia Study: Randomized Controlled Study on Effectiveness of Stepped-Care Sleep Therapy (RESTING); URL: https://clinicaltrials.gov/ct2/show/NCT03532282; Identifier: NCT03532282.
View details for DOI 10.5664/jcsm.10552
View details for PubMedID 36883379
Alterations of pain pathways by experimental sleep disturbances in humans: Central pain-inhibitory, cyclooxygenase, and endocannabinoid pathways.
There is strong evidence that sleep disturbances are an independent risk factor for the development of chronic pain conditions. The mechanisms underlying this association, however, are still not well understood. We examined the effect of experimental sleep disturbances on three pathways involved in pain initiation/resolution: (1) the central pain-inhibitory pathway, (2) the cyclooxygenase (COX) pathway, and (3) the endocannabinoid (eCB) pathway.Twenty-four healthy participants (50% females) underwent two 19-day long in-laboratory protocols in randomized order:(a) an experimental sleep disturbance protocol consisting of repeated nights of short and disrupted sleep with intermittent recovery sleep; and (b) a sleep control protocol consisting of nights with an 8-hour sleep opportunity. Pain inhibition (conditioned pain modulation, habituation to repeated pain), COX-2 expression at monocyte level (LPS-stimulated and spontaneous), and eCBs (AEA, 2-AG, DHEA, EPEA, DTEA) were measured every other day throughout the protocol.The central pain-inhibitory pathway was compromised by sleep disturbances in females, but not in males (p<0.05 condition*sex effect). The COX-2 pathway (LPS-stimulated) was activated by sleep disturbances (p<0.05 condition effect), and this effect was exclusively driven by males (p<0.05 condition*sex effect). With respect to the eCB pathway, DHEA was higher (p<0.05 condition effect) in the sleep disturbance compared to the control condition, without sex-differential effects on any eCBs.These findings suggest that central pain-inhibitory COX mechanisms through which sleep disturbances may contribute to chronic pain risk are sex specific, implicating the need for sex-differential therapeutic targets to effectively reduce chronic pain associated with sleep disturbances in both sexes.
View details for DOI 10.1093/sleep/zsad061
View details for PubMedID 36881901
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome is common in post-acute sequelae of SARS-CoV-2 infection (PASC): Results from a post-COVID-19 multidisciplinary clinic.
Frontiers in neurology
2023; 14: 1090747
The global prevalence of PASC is estimated to be present in 0·43 and based on the WHO estimation of 470 million worldwide COVID-19 infections, corresponds to around 200 million people experiencing long COVID symptoms. Despite this, its clinical features are not well-defined.We collected retrospective data from 140 patients with PASC in a post-COVID-19 clinic on demographics, risk factors, illness severity (graded as one-mild to five-severe), functional status, and 29 symptoms and principal component symptoms cluster analysis. The Institute of Medicine (IOM) 2015 criteria were used to determine the Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) phenotype.The median age was 47 years, 59.0% were female; 49.3% White, 17.2% Hispanic, 14.9% Asian, and 6.7% Black. Only 12.7% required hospitalization. Seventy-two (53.5%) patients had no known comorbid conditions. Forty-five (33.9%) were significantly debilitated. The median duration of symptoms was 285.5 days, and the number of symptoms was 12. The most common symptoms were fatigue (86.5%), post-exertional malaise (82.8%), brain fog (81.2%), unrefreshing sleep (76.7%), and lethargy (74.6%). Forty-three percent fit the criteria for ME/CFS, majority were female, and obesity (BMI > 30 Kg/m2) (P = 0.00377895) and worse functional status (P = 0.0110474) were significantly associated with ME/CFS.Most PASC patients evaluated at our clinic had no comorbid condition and were not hospitalized for acute COVID-19. One-third of patients experienced a severe decline in their functional status. About 43% had the ME/CFS subtype.
View details for DOI 10.3389/fneur.2023.1090747
View details for PubMedID 36908615
View details for PubMedCentralID PMC9998690
Daytime napping and nighttime sleep in pregnant individuals with insomnia disorder.
Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine
Examine bidirectional associations between daytime napping and nighttime sleep among pregnant individuals with insomnia disorder.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 seven-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.Sixty-three percent of participants reported napping on at least one day. Among participants in the second trimester (65%), napping 15-59 minutes was associated with 6.3% greater self-reported sleep efficiency (95% CI: 2.3, 10.2) and 0.5 units greater self-reported sleep quality (95% CI: 0.0, 0.9) that night; napping 60+ minutes was associated with 0.6 hours shorter actigraphy-measured sleep duration (95% CI: -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.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.Registry: ClinicalTrials.gov; Title: Treatment for Insomnia during Pregnancy; Identifier: NCT01846585; URL: https://clinicaltrials.gov/ct2/show/NCT01846585.
View details for DOI 10.5664/jcsm.10350
View details for PubMedID 36448328
Stepped care management of insomnia co-occurring with sleep apnea: the AIR study protocol.
2022; 23 (1): 806
BACKGROUND: Obstructive sleep apnea (OSA) and insomnia are commonly co-occurring conditions that amplify morbidity and complicates the management of affected patients. Unfortunately, previous research provides limited guidance as to what constitutes the best and most practical management approach for this comorbid patient group. Some preliminary studies show that when cognitive behavioral insomnia therapy (CBT-I) is combined with standard OSA therapies for these patients, outcomes are improved. However, the dearth of trained providers capable of delivering CBT-I has long served as a pragmatic barrier to the widespread use of this therapy in clinical practice. The emergence of sophisticated online CBT-I (OCBT-I) programs could improve access, showing promising reductions in insomnia severity. Given its putative scalability and apparent efficacy, some have argued OCBT-I should represent a 1st-stage intervention in a broader stepped care model that allocates more intensive and less assessable therapist-delivered CBT-I (TCBT-I) only to those who show an inadequate response to lower intensity OCBT-I. However, the efficacy of OCBT-I as a 1st-stage therapy within a broader stepped care management strategy for insomnia comorbid with OSA has yet to be tested with comorbid OSA/insomnia patients.METHODS/DESIGN: This dual-site randomized clinical trial will use a Sequential Multiple Assignment Randomized Trial (SMART) design to test a stepped care model relative to standard positive airway pressure (PAP) therapy and determine if (1) augmentation of PAP therapy with OCBT-I improves short-term outcomes of comorbid OSA/insomnia and (2) providing a higher intensity 2nd-stage CBT-I to patients who show sub-optimal short-term outcomes with OCBT-I+PAP improves short and longer-term outcomes. After completing baseline assessment, the comorbid OSA/insomnia patients enrolled will be randomized to a 1st-stage therapy that includes usual care PAP + OCBT-I or UC (usual care PAP + sleep hygiene education). Insomnia will be reassessed after 8 weeks. OCBT-I recipients who meet "remission" criteria (defined as an Insomnia Severity Index score < 10) will continue PAP but will not be offered any additional insomnia intervention and will complete study outcome measures again after an additional 8weeks and at 3 and 6 month follow-ups. OCBT-I recipients classified as "unremitted" after 8 weeks of treatment will be re-randomized to a 2nd-stage treatment consisting of continued, extended access to OCBT-I or a switch to TCBT-I. Those receiving the 2nd-stage intervention as well as the UC group will be reassessed after another 8 weeks and at 3- and 6-month follow-up time points. The primary outcome will be insomnia remission. Secondary outcomes will include subjective and objective sleep data, including sleep time, sleep efficiency, fatigue ratings, PAP adherence, sleepiness ratings, sleep/wake functioning ratings, and objective daytime alertness.DISCUSSION: This study will provide new information about optimal interventions for patients with comorbid OSA and insomnia to inform future clinical decision-making processes.TRIAL REGISTRATION: ClinicalTrials.gov, NCT03109210 , registered on April 12, 2017, prospectively registered.
View details for DOI 10.1186/s13063-022-06753-4
View details for PubMedID 36153634
ASSOCIATIONS BETWEEN ANHEDONIA AND MALADAPTIVE BELIEFS ABOUT SLEEP IN MIDDLE AGE AND OLDER ADULTS WITH INSOMNIA DISORDER
OXFORD UNIV PRESS INC. 2022: A286-A287
View details for Web of Science ID 000838094800648
EXPLORING DIFFERENCES IN SELF-REPORT SLEEP MEASURES IN ADULTS WITH INSOMNIA WHO USE OR DO NOT USE SLEEP MEDICATION
OXFORD UNIV PRESS INC. 2022: A206
View details for Web of Science ID 000838094800461
ASSOCIATIONS OF INDIVIDUAL BEHAVIORS AND AMBIENT FACTORS IN THE SLEEP ENVIRONMENT WITH NIGHTTIME SLEEP PARAMETERS IN PREGNANT WOMEN WITH INSOMNIA
OXFORD UNIV PRESS INC. 2022: A188-A189
View details for Web of Science ID 000838094800419
PREFERENCE FOR DIGITAL CBTI: CHANGES DUE TO THE COVID-19 PANDEMIC IN A RANDOMIZED CONTROLLED TRIAL OF CBTI FOR MIDDLE AGED AND OLDER ADULTS
OXFORD UNIV PRESS INC. 2022: A206-A207
View details for Web of Science ID 000838094800463
PRESCRIBING PATTERNS FOR HYPNOTIC MEDICATION AMONG ADULTS SEEKING CBTI TREATMENT: A PRELIMINARY REPORT FROM THE RESTING STUDY
OXFORD UNIV PRESS INC. 2022: A212
View details for Web of Science ID 000838094800475
PREDICTORS OF RESPONSE TO DIGITAL CBTI IN A RANDOMIZED CONTROLLED TRIAL OF MIDDLE AGED AND OLDER ADULTS WITH INSOMNIA
OXFORD UNIV PRESS INC. 2022: A207
View details for Web of Science ID 000838094800464
THE APNEA AND INSOMNIA RESEARCH (AIR) TRIAL: AN INTERIM REPORT
OXFORD UNIV PRESS INC. 2022: A207
View details for Web of Science ID 000838094800465
LIVING ALONE AS A PREDICTOR OF SYMPTOM CHANGE DURING COGNITIVE BEHAVIORAL THERAPY FOR INSOMNIA
OXFORD UNIV PRESS INC. 2022: A206
View details for Web of Science ID 000838094800462
THE FIRST STEP OF A TRIAGED STEPPED-CARE DELIVERY OF CBTI: A PRELIMINARY REPORT FROM THE RESTING STUDY
OXFORD UNIV PRESS INC. 2022: A203
View details for Web of Science ID 000838094800455
RCT of the effectiveness of stepped-care sleep therapy in general practice: The RESTING study protocol.
Contemporary clinical trials
Cognitive behavioral therapy for insomnia (CBT-I) is an effective, non-pharmacological intervention, designated by the American College of Physicians as the first-line treatment of insomnia disorder. The current randomized controlled study uses a Hybrid-Type-1 design to compare the effectiveness and implementation potential of two approaches to delivering CBT-I in primary care. One approach offers therapy to all patients through an automated, digital CBT-I program (ONLINE-ONLY). The other is a triaged STEPPED-CARE approach that uses a simple Decision Checklist to start patients in either digital or therapist-led treatment; patients making insufficient progress with digital treatment at 2 months are switched to therapist-led treatment. We will randomize 240 individuals (age 50 or older) with insomnia disorder to ONLINE-ONLY or STEPPED-CARE arms. The primary outcomes are insomnia severity and hypnotic medication use, assessed at baseline and at months 2, 4, 6, 9, and 12 after randomization. We hypothesize that STEPPED-CARE will be superior to ONLINE-ONLY in reducing insomnia severity and hypnotic use. We also aim to validate the Decision Checklist and explore moderators of outcome. Additionally, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we will use mixed methods to obtain data on the potential for future dissemination and implementation of each approach. This triaged stepped-care approach has the potential to improve sleep, reduce use of hypnotic medications, promote safety, offer convenient access to treatment, and support dissemination of CBT-I to a large number of patients currently facing barriers to accessing treatment. Clinical trial registration:NCT03532282.
View details for DOI 10.1016/j.cct.2022.106749
View details for PubMedID 35367385
Differential effects of an experimental model of prolonged sleep disturbance on inflammation in healthy females and males.
2022; 1 (1)
Sleep disturbances, including disrupted sleep and short sleep duration, are highly prevalent and are prospectively associated with an increased risk for various widespread diseases, including cardiometabolic, neurodegenerative, chronic pain, and autoimmune diseases. Systemic inflammation, which has been observed in populations experiencing sleep disturbances, may mechanistically link disturbed sleep with increased disease risks. To determine whether sleep disturbances are causally responsible for the inflammatory changes reported in population-based studies, we developed a 19-day in-hospital experimental model of prolonged sleep disturbance inducing disrupted and shortened sleep. The model included delayed sleep onset, frequent nighttime awakenings, and advanced sleep offset, interspersed with intermittent nights of undisturbed sleep. This pattern aimed at providing an ecologically highly valid experimental model of the typical sleep disturbances often reported in the general and patient populations. Unexpectedly, the experimental sleep disturbance model reduced several of the assessed proinflammatory markers, namely interleukin(IL)-6 production by monocytes and plasma levels of IL-6 and C-reactive protein (CRP), presumably due to intermittent increases in the counterinflammatory hormone cortisol. Striking sex differences were observed with females presenting a reduction in proinflammatory markers and males showing a predominantly proinflammatory response and reductions of cortisol levels. Our findings indicate that sleep disturbances causally dysregulate inflammatory pathways, with opposing effects in females and males. These results have the potential to advance our mechanistic understanding of the pronounced sexual dimorphism in the many diseases for which sleep disturbances are a risk factor.
View details for DOI 10.1093/pnasnexus/pgac004
View details for PubMedID 36380854
CHARACTERISTICS ASSOCIATED WITH NAPPING AMONG PREGNANT WOMEN WITH INSOMNIA
OXFORD UNIV PRESS INC. 2021: A132
View details for Web of Science ID 000698984300329
AGE IS ONLY A NUMBER: TREATMENT MODALITY PREFERENCES IN A RANDOMIZED CONTROLLED TRIAL OF CBTI IN OLDER ADULTS
OXFORD UNIV PRESS INC. 2021: A264
View details for Web of Science ID 000698984300674
HISTORICAL USE OF SUBSTANCES FOR INSOMNIA IMPACTS CURRENT BELIEFS ABOUT HYPNOTIC MEDICATIONS
OXFORD UNIV PRESS INC. 2021: A148
View details for Web of Science ID 000698984300372
MEASURING DAYTIME SLEEPINESS IN INSOMNIA DISORDER
OXFORD UNIV PRESS INC. 2021: A151-A152
View details for Web of Science ID 000698984300381
EXAMINING USE AND BELIEFS ABOUT SLEEP MEDICATIONS IN A SAMPLE OF OLDER ADULTS: THE ROLE OF HYPNOTIC DEPENDENCY
OXFORD UNIV PRESS INC. 2021: A142
View details for Web of Science ID 000698984300355
EVENING CHRONOTYPE PREDICTS SUBJECTIVE SLEEP SYMPTOM SEVERITY IN PREGNANT WOMEN WITH INSOMNIA DISORDER
OXFORD UNIV PRESS INC. 2021: A151
View details for Web of Science ID 000698984300380
- Extending the reach of cognitive behavioral therapy for insomnia via telemedicine. Sleep 2021; 44 (1)
- Treating Insomnia during the COVID-19 Pandemic: Observations and Perspectives from a Behavioral Sleep Medicine Clinic. Behavioral sleep medicine 2020: 1–3
- Insomnia and obstetric outcomes MOSBY-ELSEVIER. 2020: S110–S111
Mothers' postpartum sleep disturbance is associated with the ability to sustain sensitivity toward infants.
2019; 65: 74–83
BACKGROUND/OBJECTIVE: Infancy is a period of rapid development when the quality of caregiving behavior may be particularly consequential for children's long-term functioning. During this critical period for caregiving behavior, parents experience changes in their sleep that may affect their ability to provide sensitive care. The current study investigated the association of mothers' sleep disturbance with both levels and trajectories of maternal sensitivity during interactions with their infants.METHODS: At 18 weeks postpartum, mothers and their infants were observed during a home-based 10-minute "free play" interaction. Mothers' nighttime sleep was objectively measured using actigraphy and subjectively measured using sleep diaries. Maternal sensitivity was coded in two-minute intervals in order to characterize changes in sensitivity across the free play interaction. We used exploratory factor analysis to reduce the dimensionality of the objective and subjective measures of mothers' sleep, identifying a subjective sleep disturbance and an objective sleep continuity factor.RESULTS: Using multi-level modeling, we found that mothers with poorer objective sleep continuity evidenced decreasing sensitivity toward their infants across the interaction. Mothers' self-reports of sleep disturbance were not associated with maternal sensitivity.CONCLUSIONS: Although future research is necessary to identify the mechanisms that may explain the observed association between poor sleep continuity and the inability to sustain sensitivity toward infants, mothers' postpartum sleep continuity may be one factor to consider when designing interventions to improve the quality of caregiving.CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, NCT01846585.
View details for DOI 10.1016/j.sleep.2019.07.017
View details for PubMedID 31734620
Sleep deficiency and chronic pain: potential underlying mechanisms and clinical implications.
Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology
Pain can be both a cause and a consequence of sleep deficiency. This bidirectional relationship between sleep and pain has important implications for clinical management of patients, but also for chronic pain prevention and public health more broadly. The review that follows will provide an overview of the neurobiological evidence of mechanisms thought to be involved in the modulation of pain by sleep deficiency, including the opioid, monoaminergic, orexinergic, immune, melatonin, and endocannabinoid systems; the hypothalamus-pituitary-adrenal axis; and adenosine and nitric oxide signaling. In addition, it will provide a broad overview of pharmacological and non-pharmacological approaches for the management of chronic pain comorbid with sleep disturbances and for the management of postoperative pain, as well as discuss the effects of sleep-disturbing medications on pain amplification.
View details for DOI 10.1038/s41386-019-0439-z
View details for PubMedID 31207606
- Cognitive Behavioral Therapy for Prenatal Insomnia A Randomized Controlled Trial LIPPINCOTT WILLIAMS & WILKINS. 2019: 911–19
Cognitive Behavioral Therapy for Prenatal Insomnia: A Randomized Controlled Trial.
Obstetrics and gynecology
OBJECTIVE: To evaluate the effectiveness of cognitive behavioral therapy for insomnia during pregnancy.METHODS: Randomized, unmasked, 3-site controlled trial. Participants were randomly allocated to cognitive behavioral therapy for insomnia (a first-line, empirically supported psychosocial intervention that addresses sleep-related behaviors and cognitions) or a control intervention consisting of imagery exercises that paired patient-identified distressing nighttime experiences with patient-identified neutral images. Participants were eligible if they met diagnostic criteria for insomnia disorder and were between 18 and 32 weeks of gestation. Patients were ineligible if they met diagnostic criteria for major psychiatric disorders, including depression, or were receiving nonstudy treatments that could affect sleep (or both). The primary outcome was the Insomnia Severity Index score, a validated brief questionnaire, with scores between 14 and 21 representing clinically meaningful insomnia of moderate severity, scores higher than 21 representing severe insomnia, and scores less than 8 representing no insomnia. Secondary outcomes included remission of insomnia (Insomnia Severity Index score less than 8), objectively measured and self-reported time awake (ie, total wake time), and the Edinburgh Postnatal Depression Scale score. All outcomes were measured weekly. Analysis included 48 participants who did not complete treatment. We estimated that 184 women would be required to have 80% power, with a two-tailed test, to detect a moderate Cohen's d effect size (.5) with alpha=.05.RESULTS: Between May 2013 and April 2017, 194 pregnant women were randomized and 149 completed treatment; 179 with available baseline data (92%) were ultimately analyzed, 89 in the cognitive therapy group and 90 in the control group. Women assigned to cognitive behavioral therapy for insomnia experienced significantly greater reductions in insomnia severity (scores decreased from 15.4±4.3 to 8.0±5.2 in the cognitive behavioral therapy group vs from 15.9±4.4 to 11.2±4.9 in the control therapy group [P<.001, d=0.5]). Remission of insomnia (to an Insomnia Severity Index score less than 8) disorder was attained by 64% of women in the cognitive behavioral therapy for insomnia group vs 52% in the control group. Women receiving cognitive behavioral therapy for insomnia experienced faster remission of insomnia disorder, with a median of 31 days vs 48 days in the control therapy (P<.001). Cognitive behavioral therapy for insomnia led to significantly greater reduction in self-reported but not objective total wake time and a small but significantly greater decline in Edinburgh Postnatal Depression Scale scores vs the control group.CONCLUSION: Cognitive behavioral therapy for insomnia is an effective nonpharmacologic treatment for insomnia during pregnancy.CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT01846585.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
View details for PubMedID 30969203
SUBJECTIVE SLEEP QUALITY IN POSTPARTUM WOMEN ENROLLED IN A STUDY OF CBT FOR INSOMNIA
OXFORD UNIV PRESS INC. 2019
View details for Web of Science ID 000471071001136
DEVELOPMENT OF A SLEEP EDUCATIONAL RESOURCE FOR STUDENT ATHLETES
OXFORD UNIV PRESS INC. 2019: A394
View details for Web of Science ID 000471071004001
ACTIGRAPHY MEASURES OF MATERNAL SLEEP DISRUPTION ARE ASSOCIATED WITH THE INABILITY TO SUSTAIN SENSITIVE CAREGIVING IN THE POSTPARTUM PERIOD
OXFORD UNIV PRESS INC. 2019
View details for Web of Science ID 000471071001161
CBT FOR PERINATAL INSOMNIA - POSTPARTUM OUTCOME
OXFORD UNIV PRESS INC. 2019
View details for Web of Science ID 000471071001162
- Heart rate variability rebound following exposure to persistent and repetitive sleep restriction SLEEP 2019; 42 (2)
- Chronic exposure to insufficient sleep alters processes of pain habituation and sensitization PAIN 2018; 159 (1): 33–40
Chronic exposure to insufficient sleep alters processes of pain habituation and sensitization.
2018; 159 (1): 33-40
Chronic pain conditions are highly comorbid with insufficient sleep. While the mechanistic relationships between the 2 are not understood, chronic insufficient sleep may be 1 pathway through which central pain-modulatory circuits deteriorate, thereby contributing to chronic pain vulnerability over time. To test this hypothesis, an in-laboratory model of 3 weeks of restricted sleep with limited recovery (5 nights of 4-hour sleep per night followed by 2 nights of 8-hour sleep per night) was compared with 3 weeks of 8-hour sleep per night (control protocol). Seventeen healthy adults participated, with 14 completing both 3-week protocols. Measures of spontaneous pain, heat-pain thresholds, cold-pain tolerance (measuring habituation to cold over several weeks), and temporal summation of pain (examining the slope of pain ratings during cold water immersion) were assessed at multiple points during each protocol. Compared with the control protocol, participants in the sleep-restriction protocol experienced mild increases in spontaneous pain (P < 0.05). Heat-pain thresholds decreased after the first week of sleep restriction (P < 0.05) but normalized with longer exposure to sleep restriction. By contrast, chronic exposure to restricted sleep was associated with decreased habituation to, and increased temporal summation in response to cold pain (both P < 0.05), although only in the past 2 weeks of the sleep-restriction protocol. These changes may reflect abnormalities in central pain-modulatory processes. Limited recovery sleep did not completely resolve these alterations in pain-modulatory processes, indicating that more extensive recovery sleep is required. Results suggest that exposure to chronic insufficient sleep may increase vulnerability to chronic pain by altering processes of pain habituation and sensitization.
View details for DOI 10.1097/j.pain.0000000000001053
View details for PubMedID 28891869
View details for PubMedCentralID PMC5832516
Optimizing sleep to maximize performance: implications and recommendations for elite athletes
SCANDINAVIAN JOURNAL OF MEDICINE & SCIENCE IN SPORTS
2017; 27 (3): 266-274
Despite a growing body of literature demonstrating a positive relationship between sleep and optimal performance, athletes often have low sleep quality and quantity. Insufficient sleep among athletes may be due to scheduling constraints and the low priority of sleep relative to other training demands, as well as a lack of awareness of the role of sleep in optimizing athletic performance. Domains of athletic performance (e.g., speed and endurance), neurocognitive function (e.g., attention and memory), and physical health (e.g., illness and injury risk, and weight maintenance) have all been shown to be negatively affected by insufficient sleep or experimentally modeled sleep restriction. However, healthy adults are notoriously poor at self-assessing the magnitude of the impact of sleep loss, underscoring the need for increased awareness of the importance of sleep among both elite athletes and practitioners managing their care. Strategies to optimize sleep quality and quantity in athletes include approaches for expanding total sleep duration, improving sleep environment, and identifying potential sleep disorders.
View details for DOI 10.1111/sms.12703
View details for Web of Science ID 000394615800001
View details for PubMedID 27367265
Repeating patterns of sleep restriction and recovery: Do we get used to it?
BRAIN BEHAVIOR AND IMMUNITY
2016; 58: 142-151
Despite its prevalence in modern society, little is known about the long-term impact of restricting sleep during the week and 'catching up' on weekends. This common sleep pattern was experimentally modeled with three weeks of 5 nights of sleep restricted to 4h followed by two nights of 8-h recovery sleep. In an intra-individual design, 14 healthy adults completed both the sleep restriction and an 8-h control condition, and the subjective impact and the effects on physiological markers of stress (cortisol, the inflammatory marker IL-6, glucocorticoid receptor sensitivity) were assessed. Sleep restriction was not perceived to be subjectively stressful and some degree of resilience or resistance to the effects of sleep restriction was observed in subjective domains. In contrast, physiological stress response systems remain activated with repeated exposures to sleep restriction and limited recovery opportunity. Morning IL-6 expression in monocytes was significantly increased during week 2 and 3 of sleep restriction, and remained increased after recovery sleep in week 2 (p<0.05) and week 3 (p<0.09). Serum cortisol showed a significantly dysregulated 24h-rhythm during weeks 1, 2, and 3 of sleep restriction, with elevated morning cortisol, and decreased cortisol in the second half of the night. Glucocorticoid sensitivity of monocytes was increased, rather than decreased, during the sleep restriction and sleep recovery portion of each week. These results suggest a disrupted interplay between the hypothalamic-pituitary-adrenal and inflammatory systems in the context of repeated exposure to sleep restriction and recovery. The observed dissociation between subjective and physiological responses may help explain why many individuals continue with the behavior pattern of restricting and recovering sleep over long time periods, despite a cumulative deleterious physiological effect.
View details for DOI 10.1016/j.bbi.2016.06.001
View details for Web of Science ID 000385905600018
View details for PubMedID 27263430
View details for PubMedCentralID PMC5067189
Sleep characteristics as predictor variables of stress systems markers in insomnia disorder
JOURNAL OF SLEEP RESEARCH
2015; 24 (3): 296-304
This study investigates the extent to which sleep characteristics serve as predictor variables for inflammatory, hypothalamic-pituitary-adrenal and autonomic systems markers. Twenty-nine participants with a diagnosis of insomnia disorder based on the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (age 25.3 ± 1.6 years, insomnia duration 6.6 ± 0.8 years) and 19 healthy control sleepers (age 25.4 ± 1.4 years) underwent a 2-week at-home evaluation keeping a sleep diary and wearing an actigraph, followed by a visit to the Research Center to measure blood pressure, and collect blood and urine samples. The actigraphy- and diary-based variables of sleep duration, sleep-onset latency, wake after sleep onset and sleep fragmentation/number of night-time awakenings were averaged and entered as dependent variables in regression analyses. Composite scores were calculated for the autonomic (blood pressure, norepinephrine), inflammatory (monocyte counts, interleukin-6, C-reactive protein) and hypothalamic-pituitary-adrenal systems (cortisol), and used as predictor variables in regression models. Compared with controls, individuals with insomnia had a shorter sleep duration (P < 0.05), and a higher hypothalamic-pituitary-adrenal and inflammatory composite score (P < 0.05). The higher inflammatory score was mainly due to higher circulating monocytes (P < 0.05), rather than differences in interleukin-6 or C-reactive protein. In persistent insomnia disorder, cortisol is upregulated and associated with actigraphy- and diary-based wake after sleep onset, suggesting that wake after sleep onset may serve as a marker to identify individuals at increased risks for disorders associated with a hyperactive hypothalamic-pituitary-adrenal system. The absence of autonomic and pro-inflammatory changes (interleukin-6, C-reactive protein), despite a substantial decrease in actigraphic sleep duration, may relate to a higher resilience to the adverse biological consequences of insomnia in this young age group.
View details for DOI 10.1111/jsr.12259
View details for Web of Science ID 000354805600008
View details for PubMedID 25524529
A step towards stepped care: Delivery of CBT-I with reduced clinician time
SLEEP MEDICINE REVIEWS
2015; 19: 3–5
View details for PubMedID 25454675
Intervention Format and Delivery Preferences Among Young Adult Cancer Survivors
INTERNATIONAL JOURNAL OF BEHAVIORAL MEDICINE
2013; 20 (2): 304-310
Young adult cancer survivors face a number of increased medical and psychosocial risks, including an increased risk of cardiovascular disease and emotional distress. Although behavioral strategies, such as exercise, may diminish some of these risks, few behavioral interventions have been developed for this population.As a first step toward developing interventions specifically for young survivors, we conducted a qualitative study of their intervention-related preferences. A key objective was to identify the preferred format for delivering interventions (e.g., face-to-face, online).In-depth, semi-structured individual interviews were conducted with 20 young adult cancer survivors between the ages of 18 and 39. This research was conducted in Rhode Island, USA.Participants identified advantages and disadvantages to a variety of intervention formats including: telephone-based, print-based, computer-based, and several types of face-to-face interventions. The dominant theme that emerged was that interventions developed for young adult cancer survivors should take into account their multiple competing needs and obligations (e.g., work, family). Two closely related subthemes were: (1) the importance of developing interventions that are convenient and (2) the need for interventions that provide social support. Interventions for this population may be most successful if they take into account these themes.Data indicate that young adult cancer survivors have some unique needs (e.g., multiple competing demands of young adulthood) and preferences (e.g., comfort with remotely delivered interventions) that differentiate them from older cancer survivors. Thus, young survivors would be best served by interventions designed to specifically target this population.
View details for DOI 10.1007/s12529-012-9227-4
View details for Web of Science ID 000318505900018
View details for PubMedID 22328444