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Clinical Characteristics of Primary Insomniacs with Sleep-State Misperception

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Clinical Characteristics of Primary Insomniacs with Sleep-State Misperception JCN Open Access ORIGINAL ARTICLE pISSN 1738-6586 / eISSN 2005-5013 / J Clin Neurol 2015;11(4):358-363 / http://dx.doi.org/10.3988/jcn.2015.11.4.358 Clinical Characteristics of Primary Insomniacs with Sleep-State Misperception Hye-Jin Moona b Background and PurposezzThe aims of this study were to determine the prevalence of Mei Ling Song a sleep-state misperception and to identify any differences in the clinical characteristics of pri- Yong Won Cho mary insomniacs with and without misperception. a Department of Neurology and MethodszzIn total, 250 adult primary insomniacs were enrolled whose objective total sleep b Nursing Graduate School, time (TST) was more than 120 min, as assessed by full-night polysomnography. Sleep state Dongsan Medical Center, misperception was defined objectively as a TST of at least 6.5 h and an objective sleep effi- Keimyung University School of Medicine, Daegu, Korea ciency (SE) of at least 85%. ResultszzThe prevalence of sleep-state misperception in primary insomniacs was 26.4%. The (low) quality of sleep and psychiatric parameters were similar in the two groups, al- though the objective sleep architecture was relatively normal for the misperception group. Multivariate analysis revealed that both SE and sleep quality were significant factors associat- ed with subjective TST in the misperception group, while only SE was significant in those without misperception. Subjective TST was a significant effect factor with respect to sleep quality in the misperception group, while the Beck Depression Inventory-2 score and age were significant factors in those without misperception. ConclusionszzThe clinical characteristics of patients with sleep-state misperception differed from those without this condition. This suggests that these two groups should be separated and the treatment goals tailored specifically to each. Key Wordszz insomnia, sleep-state misperception, sleep disorders. INTRODUCTION Sleep-state misperception, which is also known as subjective insomnia and paradoxical insomnia, is considered a subtype of primary insomnia,1,2 and describes people who mis- takenly underestimate their total sleep time (TST) relative to the normal TST, as assessed using objective studies such as polysomnography (PSG) or actigraphy. Although no large- scale, community-based studies have investigated the prevalence of sleep-state mispercep- tion and its variable definitions, some studies have investigated the prevalence of this dis- order, and found it to be 9.2–50%.3-9 These prevalence studies suggest that sleep-state misperception is a relatively common condition among primary insomnia sufferers. Received January 26, 2015 Insomnia is a common complaint in Korean adults, with about 22.8% reportedly suf- Revised April 5, 2015 fering from primary insomnia, a rate that is similar to that reported for Western coun- Accepted April 6, 2015 tries.10 However, to the best of our knowledge there have been no studies on the preva- Correspondence Yong Won Cho, MD lence of sleep-state misperception and its associated factors in Asian adults. Department of Neurology, The purpose of this study was to identify the prevalence of sleep-state misperception in Keimyung University primary insomnia sufferers and to assess the clinical predictors of this disorder in primary School of Medicine, 56 Dalseong-ro, Jung-gu, Daegu 41931, Korea insomniacs. Tel +82-53-250-7831 cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Com- Fax +82-53-250-7840 mercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial E-mail [email protected] use, distribution, and reproduction in any medium, provided the original work is properly cited. 358 Copyright © 2015 Korean Neurological Association Moon HJ et al. JCN METHODS Subjective measures Before the full-night PSG study, all of the subjects complet- Subjects ed the self-reported questionnaires with demographic fac- Two hundred and fifty primary insomnia patients who vis- tors, health/medical history, sleep-related scales, and psy- ited a regional sleep center between April 2009 and Octo- chiatric measurements including the Korean versions of the ber 2013 were retrospectively selected from a sleep center Insomnia Severity Index (K-ISI),14 Pittsburgh Sleep Quality registry. Primary insomnia was diagnosed according to the Index (K-PSQI),15 Epworth Sleepiness Scale (K-ESS),16 Beck fourth edition of the Diagnostic and Statistical Manual, text Depression Inventory-2 (K-BDI-2),17 Hospital Anxiety and revision.11 All subjects who were selected in our study were Depression Scale,18 and Short-Form 36-Item Health Survey.19 older than 18 years and had an objective TST of >120 min. In the morning after a full-night PSG, all subjects were Patients with other comorbid sleep disorders such as ob- interviewed by a PSG technician. Their TST of the previous structive sleep apnea and restless legs syndrome were ex- night was estimated by the hour and they were asked wheth- cluded, as were those who did not complete a full-night er they thought it had been an ordinary night. The sleep es- PSG, self-reported questionnaire, or interview regarding timation error was calculated by subtracting the objective subjectively estimated TST the morning after the PSG. In- TST from the subjective TST (PSG) values. somniacs who answered that the previous night’s sleep dif- fered from their usual sleep experience were also excluded. Statistical analysis The selected patients were divided into two groups accord- The data analyses were performed using SPSS version 18.0, ing to the presence or absence of sleep-state misperception, and the threshold for statistical significance was set at p<0.05. which was defined according to the research criteria for par- Descriptive statistics were used to examine the demograph- adoxical insomnia, by an objective TST of at least 6.5 h and ic data. Analysis of covariance (ANCOVA) was used to ana- an objective sleep efficiency (SE) of at least 85%.12 lyze sleep- and psychiatric-related characteristics, and for some Ethical approval for this study was obtained from the lo- of the PSG variables. The factors related to subjective TST and cal institutional review board. sleep quality were analyzed using stepwise regression. Except where stated otherwise, the data are presented as mean±SD Full-night PSG values. A full-night PSG consists of continuous recordings from six electroencephalogram leads (C3-A2, C4-A1, F3-A2, F4- RESULTS A1, O1-A2, and O2-A1 in the international 10–20 system), two electro-oculogram leads (ROC-A1 and LOC-A2), and Among 250 primary insomniacs, 66 (26.4%) were classified three electromyogram leads (submental and bilateral tibia- as having sleep-state misperception; their demographic and lis anterior). The equipment includes thermistors for mea- clinical characteristics are listed in Table 1. The patients suring the temperatures of the nasal and oral airflows, an with misperception were significantly younger than those airflow pressure transducer for measuring nasal air pressure, without misperception (47.48±12.63 years vs. 54.24±11.32 a microphone for snore detection, strain gauges for mea- years, p<0.001). There were no significant differences be- suring thoracic and abdominal excursion, finger pulse ox- tween the two groups with respect to other variables such imetry, and electrocardiogram leads. Each epoch is staged as gender, body mass index, and underlying diseases. and scored according to the international criteria of the 2007 The PSG data of the patients with and without misper- manual from the American Academy of Sleep Medicine.13 ception groups are listed in Table 2. The misperception group exhibited relatively normal sleep architecture; their Table 1. Characteristics of patients with and without sleep-state misperception With sleep-state misperception (n=66) Without sleep-state misperception (n=184) p Age (years) 47.48±12.63 54.24±11.32 <0.001 Gender (female, %) 63 (67.0) 109 (69.9) 0.637 Body mass index (kg/m2) 22.40±3.12 23.10±2.81 0.094 Alcohol (yes, %) 17 (25.8) 35 (19.0) 0.247 Smoking (yes, %) 6 (9.1) 14 (7.6) 0.703 Diseases (yes, %) 29 (43.9) 102 (55.4) 0.109 Data are either mean±SD or n (%) values. www.thejcn.com 359 JCN Characteristics of Insomniacs with Misperception total recording times (470.56±21.42 min vs. 457.00±24.22 K-ESS scores were within the normal limits, the K-ISI scores min, p<0.001) and TST (422.80±22.67 min vs. 304.38±66.73 revealed moderate insomnia in both groups (21.64±4.67 vs. min, p<0.001) were significantly longer than in those without 21.70±4.84), and the total K-PSQI score revealed poor sleep misperception, and their latency to sleep onset (6.94±4.78 quality in both groups (14.38±3.26 vs. 15.19±2.93). The psy- min vs. 24.54±25.02 min, p<0.001) and latency to rapid eye chiatric variables did not differ significantly between the two movement sleep (REM; 90.40±47.79 min vs. 131.25±82.93 groups, with both groups demonstrating a moderate depres- min, p<0.001) were significantly shorter. The misperception sive mood, anxiety, and poor quality of life. group had a shorter wake-after-sleep onset time (40.82± Multivariate analysis was used to determine the factors 13.64 min vs. 128.07±55.97 min, p<0.001) and better SE affecting subjective TST and subjective sleep quality. In (89.25±2.80% vs. 66.55±14.08%, p<0.001). Furthermore, both groups, the objective SE, as calculated from the PSG, the misperception group had a nearly normal sleep archi- was a significant factor associated with subjective TST (Ta- tecture, while those without misperception had a shorter ble 5).
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