Sleep Initiation and Maintenance Disorders: Riemann D

Perlis M, Gehrman P, Riemann D. · Penn Behavioral Sleep Medicine Program, Suite 670, Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Philadelphia PA, USA. · Curr Pharm Des. · Pubmed #19075721 No free full text.

Abstract: In this review, the context and evidence base for intermittent and long term dosing with hypnotics is critically evaluated. The context provided includes addressing two questions: "why has long term or maintenance therapy not been a standard for practice for the treatment of chronic insomnia?"; and "why is intermittent dosing thought to represent a potential solution for the problem of chronic insomnia?". The data from the systematic review suggests, over all, that: 1) while intermittent dosing can be conducted without resulting in rebound insomnia on non-med nights, there is insufficient data to show that the strategy is equal, or superior, to nightly dosing on a long term basis; 2) long term therapy (up to 6 months) with intermittent or nightly dosing appears viable to the extent that clinical outcomes are stable over time and occur in the absence of dose escalation or increased adverse events. The discussion section of the review includes: an analysis of the future prospects for intermittent dosing (with or without placebos); the suggestion that the use of placebos in an intermittent dosing regimen presages the use of partial reinforcement principles to enhance the safety and efficacy of the approach; finally the discussion contains a challenge to re-think, from first principles, whether the underlying approach to the medical management of insomnia is rational. It is suggested that a more rational approach is possible and that medical therapy for insomnia needs to be re-assessed for it's curative (vs palliative) potential.

Doerr JP, Riemann D. · Abteilung für Psychiatrie und Psychotherapie der Universitätsklinik Freiburg, Hauptstr. 5, D-79104 Freiburg. · Pharm Unserer Zeit. · Pubmed #18446906 No free full text.

This publication has no abstract.

Riemann D. · Freiburg University Medical Center, Freiburg, Germany. · Sleep Med. · Pubmed #18346672 No free full text.

Abstract: Defining the relationship between sleep disturbances and psychiatric disorders is a thought-provoking task and is becoming even more challenging because it is apparent that insomnia is not simply a typical symptom of a psychiatric disorder but may actually be a predictor (or independent risk factor) for the development of such a condition. Studies have shown that depressed patients not only have disturbances in sleep continuity but have reduced slow wave sleep and disinhibited REM sleep. In particular, REM sleep regulation is characterized by shortened REM latency and increased REM density. It has been suggested that the reciprocal interaction between REM and nonREM sleep, driven by inhibitory aminergic and excitatory cholinergic activity, becomes unbalanced in depression. Exposure to cholinergic stimulants reduces REM latency, particularly in major depressive disorder. In fact, it has been shown that healthy individuals at high risk for developing depression have greater sensitivity to cholinergic stimulation than those not at high risk. While the causality of the insomnia-depression relationship is debated, epidemiological studies have indicated that insomnia is an independent risk factor for depression and other psychiatric disorders. As we learn more about the interplay between these pathophysiologies, we will be able to make better treatment decisions for our patients.

Hornyak M, Feige B, Riemann D, Voderholzer U. · Department of Psychiatry and Psychotherapy, University Hospital Freiburg, Hauptstrasse 5, D-79104 Freiburg, Germany. · Sleep Med Rev. · Pubmed #16762807 No free full text.

Abstract: Periodic leg movements in sleep (PLMS) are a frequent finding in polysomnography. The prevalence of PLMS is estimated to be 4-11% in adults. In childhood, PLMS rarely occur although medical conditions like sleep apnea syndrome or neuropsychiatric disorders can lead to high rates of PLMS. In the elderly, PLMS are also common in subjects without sleep disturbances. In sleep studies, PLMS are found most frequently in restless legs syndrome (RLS) and often occur in narcolepsy, sleep apnea syndrome and REM sleep behavior disorder. Some patients with otherwise unexplained insomnia or hypersomnia reveal an elevated number of PLMS, a condition defined as periodic limb movement disorder (PLMD). PLMS were found also in various medical and neurological disorders that do not primarily affect sleep. A summary of these is presented. In sleep disorders related to dopaminergic dysfunction such as RLS, PLMS are considered to be a symptom of the disease. In other disorders like primary insomnia, the clinical relevance of PLMS is still being controversially discussed. Studies with findings both pro and contra are referred. To date, only a few studies have evaluated the efficacy of therapeutic substances in reducing PLMS in PLMD patients. Their results need to be confirmed in controlled randomized trials.

Riemann D, Hornyak M, Voderholzer U, Berger M. · Abteilung für Allgemeine Psychiatrie und Psychotherapie mit Poliklinik, Universitätsklinik der Albert-Ludwigs-Universität Freiburg i. Br. · MMW Fortschr Med. · Pubmed #14579486 No free full text.

Abstract: Complaints of insomnia, i.e. problems to fall asleep or maintain asleep and/or non-restorative sleep are very common in general practice. This article presents the clinical algorithm non-restorative sleep which was devised by the German Society for Sleep Research and Sleep Medicine. This algorithm presents a guideline for the diagnosis and the treatment of insomnia.

Riemann D, Voderholzer U, Berger M. · Abteilung für Allgemeine Psychiatrie und Psychotherapie mit Poliklinik, Universitätsklinik der Albert-Ludwigs-Universität Freiburg. · Nervenarzt. · Pubmed #12966821 No free full text.

Abstract: Over the last few years, a shift in paradigm has taken place in the diagnosis and therapy of insomnia. Traditionally, treatment focused on improving night sleep, i.e. shortening sleep latency and prolonging total sleep time. Modern approaches aim at improving or restoring the recuperative value of sleep and ensuring daytime functioning on a social, psychological and professional level. Based on the guidelines "Non-restorative Sleep" of the German Society of Sleep Research and Sleep Medicine, this article presents a clinical algorithm for the diagnosis and therapy of non-restorative sleep with predominant insomnia. The term "non-restorative sleep" permits us to view the restorative value of sleep and the resulting daytime functioning of the individual afflicted with insomnia as the focus for the diagnosis of and therapy for insomnia. This algorithm is suitable for the clinical practice of outpatient psychiatric and psychotherapeutic services as well as for psychiatric inpatients. The main features for psychiatrists and psychotherapists in the diagnosis and therapy of non-restorative sleep are underlying psychiatric-psychological factors or secondary psychiatric sequelae of chronic primary insomnias. For primary, organic and psychiatric insomnias, a broad spectrum of psychopharmacological and cognitive behavioral methods can be applied either alone or in combination.

Riemann D, Voderholzer U. · Department of Psychiatry and Psychotherapy, University Hospital of Freiburg, Hauptstrasse 5, 79104 Freiburg, Germany. · J Affect Disord. · Pubmed #12943956 No free full text.

Abstract: BACKGROUND: Chronic insomnia afflicts approximately 5-10% of the adult population in Western industrialized countries. Insomnia may be secondary, i.e. triggered and/or maintained by psychiatric/organic illnesses, the intake of prescribed/illicit drugs or alcohol, or by a combination of these factors. Insomnia can also occur as primary insomnia, caused by a psychophysiological hyperarousal process. In the present review a literature search was undertaken to identify longitudinal epidemiological studies which investigate the question whether primary insomnia at baseline predicts the development of depression at follow-up measurements. METHODS: MEDLINE search for the medical subject headings insomnia and depression; identification of longitudinal epidemiological studies with at least two measurement points 1 year apart measuring insomnia and depression and indicating explicit criteria for both disorders. RESULTS: Eight relevant epidemiological studies were identified. Almost unambiguously insomnia at baseline significantly predicted an increased depression risk at follow-up 1-3 years later. CONCLUSION: As insomniac symptoms alone seem to be of predictive value for the development of depression in the succeeding years, it would be worthwhile to investigate if early adequate treatment is able to prevent psychiatric sequelae of primary insomnia.

Voderholzer U, Al-Shajlawi A, Weske G, Feige B, Riemann D. · Department of Psychiatry and Psychotherapy, University Hospital of Freiburg, Germany. · Depress Anxiety. · Pubmed #12768650 No free full text.

Abstract: It is well known that insomnia is more frequent in women than in men throughout all age groups. In this respect insomnia resembles other psychiatric disorders that occur more frequently in women such as anxiety and depressive disorders. Since insomnia is frequently a symptom of anxiety and depression, it remains an open question whether the comorbidity with psychiatric disorders fully explains the gender differences in the prevalence of insomnia or whether gender influences sleep independently from psychiatric conditions. We analyzed sleep measures of patients diagnosed with a primary insomnia (n=86) and of an age- and sex-matched healthy control group (n=86) by polysomnography; additionally, subjective rating scales were available for 70 patients and 54 controls matched for mean age and sex ratio. Surprisingly, none of the sleep continuity measures (sleep duration, sleep efficiency, arousal index, and wake%), nor slow wave or REM sleep % showed significant gender differences in both insomniacs and healthy controls. Also, subjective estimates of sleep quality were comparable in both sexes. As expected, insomniacs strongly differed from the control group in all subjective measures of sleep. Polysomnography showed significantly reduced sleep duration and efficiency, increased arousal index, and slightly, but significantly, less REM sleep in the insomniacs as compared to the healthy controls. These studies indicate that gender seems to have, if any, relatively little influence on sleep per se. We hypothesize that the clear gender differences in the prevalence of insomnia are caused predominantly by gender differences in the prevalence of anxiety and depression. Primary insomnia may be, at least in a part of the cases, a subclinical or subthreshold form of anxiety or depression.

Vielhaber K, Riemann D, Feige B, Kuelz A, Kirschbaum C, Voderholzer U. · Department of Psychiatry and Psychotherapy, University Hospital of Freiburg, Germany. · Pharmacopsychiatry. · Pubmed #15744632 No free full text.

Abstract: BACKGROUND: Tryptophan depletion (TD) has been shown to induce a transient mood-lowering effect in psychiatric patients and susceptible healthy subjects. We investigated the effects of TD on cortisol secretion in psychiatric patients and healthy subjects based on the hypothesis that the potential mood-lowering effects may be associated with increased activity of the hypothalamic-pituitary-adrenal axis, thus leading to a rise of cortisol secretion. METHODS: After TD at 18.00 h, salivary cortisol was sampled in the evening and on the following morning. The first study was a randomized, placebo-controlled, crossover study in healthy subjects. Two further open trials in patients with obsessive-compulsive disorder (OCD) and primary insomnia compared the effects of TD on cortisol with baseline conditions. RESULTS: In healthy subjects, TD significantly diminished cortisol the next morning compared with placebo. In OCD patients and primary insomniacs, cortisol the morning after TD was lowered compared with baseline. Evening cortisol was not affected by TD in any of the groups. CONCLUSIONS: Contrary to expectation, TD led to a comparable decrease of morning cortisol in all groups investigated. However, these findings are consistent with former studies analyzing the impact of antiserotonergic drugs on cortisol secretion. The results underline that the antiserotonergic effects caused by TD may influence cortisol secretion.

Riemann D, Voderholzer U, Cohrs S, Rodenbeck A, Hajak G, Rüther E, Wiegand MH, Laakmann G, Baghai T, Fischer W, Hoffmann M, Hohagen F, Mayer G, Berger M. · Department of Psychiatry and Psychotherapy, University of Freiburg, Germany. · Pharmacopsychiatry. · Pubmed #12237787 No free full text.

Abstract: In recent years, sedating antidepressants have been increasingly used to treat primary insomnia. Up to now, only one open pilot study with trimipramine and one double-blind placebo-controlled study with doxepin have provided scientific support for this approach in treating primary insomnia. In order to test the hypothesis that sedating antidepressants are useful in the treatment of primary insomnia, the effect of trimipramine on objectively and subjectively measured parameters of sleep was investigated in a double-blind placebo- and lormetazepam-controlled study in a sample of 55 patients with primary insomnia attending outpatient sleep-disorder clinics. Trimipramine was selected since it has shown positive effects on sleep continuity with a lack of REM sleep suppression in studies on depressed patients and in one pilot study on patients with primary insomnia. Trimipramine at an average dose of 100 mg over a period of 4 weeks significantly enhanced sleep efficiency, but not total sleep time (which had been the primary target variable) compared to placebo as measured by polysomnography. Changes in objective sleep parameters were paralleled by changes in subjective sleep parameters. Trimipramine did not suppress REM sleep. Lormetazepam decreased wake time and sleep stage 3 and increased REM sleep compared to placebo. After switching trimipramine to placebo, sleep parameters returned to baseline. There was no evidence of any rebound effect from trimipramine. Side effects from trimipramine were only marginal. This first double-blind placebo-controlled study with trimipramine suggests its efficacy in the treatment of primary insomnia. However, due to the large intra- and interindividual variance in the parameters of interest before and during treatment a larger sample size would have been necessary to strengthen the validity of our findings.

Backhaus J, Junghanns K, Mueller-Popkes K, Broocks A, Riemann D, Hajak G, Hohagen F. · University Hospital, Department of Psychiatry and Psychotherapy, Ratzeburger Allee 160, 23538 Luebeck, Germany. · Eur Arch Psychiatry Clin Neurosci. · Pubmed #12192465 No free full text.

Abstract: OBJECTIVE: To evaluate the effect of short-term training of general practitioners (GPs) on their diagnosis and treatment of chronic insomnia. METHODS: A three-step randomized control group design was used: After baseline evaluation (T1) a group of 9 GPs underwent a training of half a day, while 7 GPs served as a control group. The diagnostic and therapeutic handling of insomnia patients was reevaluated under obligatory use of a structured diagnostic questionnaire (T2) and under optional use of it (T3). RESULTS: From 16 general practices, 4,754 patients were included. The frequency rate of insomnia was 19.3 %. The lowest diagnostic and treatment rate was found for insomnia patients without comorbidity (15 % at T1). Systematic non-pharmacological treatment was not offered by the GPs. At T2 the diagnosis rate increased significantly from 37.9 % (T1) to 71.5 % (T2, p = 0.038). It fell back to lower levels at T3 but remained better than at T1. At T3 non-pharmacological treatments and referral to a sleep expert were advised more often. CONCLUSION: Short-term training of GPs can significantly improve their diagnostic sensitivity and first-line treatment efforts against insomnia.

Voderholzer U, Riemann D, Hornyak M, Backhaus J, Feige B, Berger M, Hohagen F. · Department of Psychiatry and Psychotherapy, Klinikum of the Albert-Ludwigs-University Hauptstrasse 5 79104 Freiburg, Germany. · Eur Arch Psychiatry Clin Neurosci. · Pubmed #11697572 No free full text.

Abstract: Rebound effects after withdrawal from hypnotics are believed to trigger their chronic use and to enhance the risk of tolerance and dependence. It was the purpose of this study to investigate the acute polysomnographic withdrawal effects after a 4 week treatment with standard doses of the non-benzodiazepine hypnotics zopiclone and zolpidem compared with triazolam and placebo. Healthy male subjects between 22 and 35 years of age participated in a parallel study design. They received either zopiclone 7.5 mg (n=11), zolpidem 10 mg (n=11), triazolam 0.25 mg (n=10) or placebo (n=7) over 4 weeks in randomized and double-blind order. Sleep EEG was registered during 2 nights before treatment under placebo, on days 1, 27 and 28 of treatment and on days 29,30,41 and 42 under placebo. Total sleep time and sleep efficiency were lower in the 1st night after discontinuation of triazolam (p < 0.05, t-test). After withdrawal from zopiclone or zolpidem slight but not significant rebound effects concerning sleep continuity were observed. Self-rating scales showed minimal rebound insomnia after discontinuation of all three hypnotics. In the placebo group no changes of sleep parameters were observed. Assuming that rebound insomnia is part of a withdrawal reaction, this study indicates that the risks of tolerance and dependency are low when administering zopiclone or zolpidem at the recommended doses.

Hajak G, Rodenbeck A, Voderholzer U, Riemann D, Cohrs S, Hohagen F, Berger M, Rüther E. · Department of Psychiatry and Psychotherapy, Georg-August-University of Göttingen, Germany. · J Clin Psychiatry. · Pubmed #11465523 No free full text.

Abstract: BACKGROUND: Over recent years, the use of antidepressants for the symptomatic treatment of insomnia has grown substantially, but controlled studies are still lacking. Our study is the first investigation to prove objective efficacy and tolerability of low doses of a sedating antidepressant in a randomized, double-blind, and placebo-controlled manner in patients with primary insomnia. METHOD: Forty-seven drug-free patients meeting DSM-IV criteria for primary insomnia (mean +/- SD duration of complaints = 11.2+/-9.7 years) received either 25-50 mg of the tricyclic antidepressant doxepin or placebo for 4 weeks followed by 2 weeks of placebo withdrawal. Sleep was measured by polysomnography at baseline and the first night of application, at 4 weeks of treatment and the first to third night of withdrawal, and after 2 weeks of withdrawal. RESULTS: In the doxepin-treated patients who completed the study (N = 20, 47.6+/-11.3), medication significantly increased sleep efficiency after acute (night 1, p < or = .001) and subchronic (night 28, p < or = .05) intake compared with the patients who received placebo (N = 20, 47.4+/-16.8 years of age). Latency to sleep onset was not affected since the patients had normal baseline sleep latencies. Investigators found doxepin to cause significantly (p < or = .05) better global improvement at the first day of treatment. Patients rated sleep quality (p < or = .001) and working ability (p < or = .005) to be significantly improved by doxepin during the whole treatment period. Overall rebound in sleep parameters was not observed, but patients with severe rebound insomnia were significantly more frequent in the doxepin group (night 29, p < .01, night 30, p < or = .01; night 31, p < or = .05). No significant group differences in side effects were found, but 2 doxepin-treated patients dropped out of the study due to specific side effects (increased liver enzymes, leukopenia, and thrombopenia). CONCLUSION: The results support the effectiveness of low doses of doxepin to improve sleep and working ability in chronic primary insomniacs, although subjective effects were light to moderate, and in some patients, rebound insomnia and specific side effects have to be considered.

Backhaus J, Hohagen F, Voderholzer U, Riemann D. · Universitaetsklinikum Luebeck Klinik für Psychiatrie und Psychotherapie Ratzeburger Allee 160, 23538 Luebeck, Germany. · Eur Arch Psychiatry Clin Neurosci. · Pubmed #11315517 No free full text.

Abstract: The long-term effectiveness of a short-term cognitive-behavioral therapy was evaluated. The structured group treatment consisted of six weekly sessions and included progressive muscle relaxation, cognitive relaxation, modified stimulus control with bedtime restriction, thought stopping and cognitive restructuring. Twenty patients with chronic primary insomnia took part in the study. All patients were referred by physicians for diagnosis and therapy of insomnia. During a waiting period of six weeks prior to treatment, patients did not experience any change of their sleep parameters. After therapy, patients improved their total sleep time and sleep efficiency and reduced their sleep latency and negative sleep-related cognitions. Furthermore, depression scores decreased. Most of the treatment effects were significant at the end of the treatment and remained stable over the long-term follow-up, which was evaluated after a mean of almost three years (35 +/- 6.7 months). The subjective estimated total sleep time improved from 298 +/- 109 min prior to therapy to 351 +/- 54 min at the end of treatment, to 376 +/- 75 min at the 3-month follow-up, to 379 +/- 58 min at the 12-month follow-up and to 381 +/- 92 min. at the long-term follow-up.

Spiegelhalder K, Espie C, Nissen C, Riemann D. · Department of Psychiatry and Psychotherapy, University of Freiburg Medical Center, Freiburg, Germany. · J Sleep Res. · Pubmed #18482107 No free full text.

Abstract: Sleep-related attentional bias has been proposed to be an important factor in the development and maintenance of primary insomnia. In this study, a newly introduced mixed modality (visual auditory) task and an emotional Stroop task were used to investigate attentional processes in patients with primary insomnia, sleep experts and healthy controls (n = 20 per group). The sleep expert group served as second control group to control for effects of frequency of concept usage (FOCU). The results of the emotional Stroop task showed a sleep-related attentional bias in the insomnia group in comparison with the expert group. However, no significant differences were detected in the other group comparisons and in the mixed modality task. The difference between insomnia patients and sleep experts in the emotional Stroop task indicates that FOCU is not the underlying process of sleep-related attentional bias. Insomnia patients seem to be more emotionally, cognitively or procedurally affected by sleep-related stimuli than sleep experts. The findings suggest that a desensitization of sleep-related stimuli might be used therapeutically, thus extending the current cognitive behavioral treatments for primary insomnia.

Feige B, Al-Shajlawi A, Nissen C, Voderholzer U, Hornyak M, Spiegelhalder K, Kloepfer C, Perlis M, Riemann D. · Department of Psychiatry and Psychotherapy, University Medical Center, Freiburg, Germany. · J Sleep Res. · Pubmed #18482106 No free full text.

Abstract: Primary insomnia (PI) is characterized by low subjective sleep quality which cannot always be verified using polysomnography (PSG). To shed light on this discrepancy, subjective estimates of sleep and PSG variables were compared in patients with PI and good sleeper controls (GSC). 100 patients with PI (age: 42.57 +/- 12.50 years, medication free for at least 14 days) and 100 GSC (41.12 +/- 13.99 years) with a sex distribution of 46 men and 54 women in each group were included. Both PSG and questionnaire variables showed clear impairments of sleep quality in PI compared with GSC. The arousal index within total sleep time was increased, which was mainly because of a strong increase within rapid eye movement (REM) sleep. Subjectively, more PI than GSC subjects estimated wake times longer than obtained from PSG. Linear modeling analysis of subjective wake time in terms of PSG parameters revealed that in addition to PSG defined wake time, REM sleep time contributed significantly to subjective wake time. This REM sleep contribution was larger for PI than for GSC subjects. The findings suggest that REM sleep-related processes might contribute to subjectively disturbed sleep and the perception of waking time in patients with PI.

Riemann D, Voderholzer U, Spiegelhalder K, Hornyak M, Buysse DJ, Nissen C, Hennig J, Perlis ML, van Elst LT, Feige B. · Department of Psychiatry and Psychotherapy, Freiburg University Medical Center, Hauptstr. 5, D-79104 Germany. · Sleep. · Pubmed #17702263 links to  free full text

Abstract: STUDY OBJECTIVES: Morphometric analysis of magnetic resonance imaging brain scans was used to investigate possible neuroanatomic differences between patients with primary insomnia compared to good sleepers. DESIGN: MRI images (1.5 Tesla) of the brain were obtained from insomnia patients and good sleepers. MRI scans were analyzed bilaterally by manual morphometry for different brain areas including hippocampus, amygdala, anterior cingulate, orbitofron-tal and dorsolateral prefrontal cortex. SETTING: University Hospital Sleep Center and Radiology Department PARTICIPANTS: 8 unmedicated physician-referred patients with chronic primary insomnia (3 males, 5 females; 48.4 + 16.3 years) and 8 good sleepers matched for age, sex, body mass index, and education. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Patients with primary insomnia demonstrated significantly reduced hippocampal volumes bilaterally compared to the good sleepers. None of the other regions of interest analyzed revealed differences between the 2 groups. CONCLUSIONS: These pilot data raise the possibility that chronic insomnia is associated with alterations in brain structure. Replication of the findings in larger samples is needed to confirm the validity of the data. The integration of structural, neuropsychological, neuroendocrine and polysomnographic studies is necessary to further assess the relationships between insomnia and brain function and structure.

Nissen C, Kloepfer C, Nofzinger EA, Feige B, Voderholzer U, Riemann D. · Department of Psychiatry and Psychotherapy, Albert-Ludwigs-University of Freiburg, Freiburg, Germany. · Sleep. · Pubmed #16944676 No free full text.

Abstract: STUDY OBJECTIVES: To compare sleep-related consolidation of procedural memory in patients with primary insomnia and healthy controls. DESIGN: Controlled comparison pilot study. SETTING: Sleep Laboratory of the Department of Psychiatry and Psychotherapy, University of Freiburg, Germany. PATIENTS OR PARTICIPANTS: Seven patients with primary insomnia and 7 sex-, age-, and IQ-matched healthy controls. INTERVENTIONS: Subjects spent 1 night in the sleep laboratory with polysomnographic monitoring. Performance on a mirror tracing task was measured before and after sleep. MEASUREMENTS AND RESULTS: Polysomnography revealed a trend toward disturbed sleep in the patients, compared with the control group, without reaching significance. Performance in the mirror tracing task before sleep did not differ between the groups. Both groups performed significantly better in the retest condition after sleep. Healthy controls showed an improvement of 42.8% +/- 5.8% in the mirror tracing draw time, whereas patients with insomnia showed an improvement of 20.4% +/- 14.8% (multivariate analyses of variance test session x group interaction: F(3,10) = 10.9, p = .002). CONCLUSIONS: These preliminary findings support the view that sleep-associated consolidation of procedural memories may be impaired in patients with primary insomnia.

Burgos I, Richter L, Klein T, Fiebich B, Feige B, Lieb K, Voderholzer U, Riemann D. · Department of Psychiatry and Psychotherapy, University Hospital of Leipzig, Leipzig, Germany. · Brain Behav Immun. · Pubmed #16084689 No free full text.

Abstract: The aim of the present study was to investigate whether there is a difference in evening/nocturnal interleukin-6 (IL-6) serum excretion in patients with primary insomnia compared to controls. We hypothesized that in insomniac patients, the excretion of evening/nocturnal IL-6 is enhanced, like observed in aged adults and after sleep deprivation in healthy subjects. We studied IL-6 serum concentrations in 11 patients (two males and nine females) with primary insomnia and 11 age and gender-matched healthy controls. Sleep was monitored polysomnographically for three consecutive nights. The measurement of IL-6 (from 19:00 h to 09:00 h) in 2-h intervals were performed prior to and during the last laboratory night. Polysomnographically determined sleep parameters and subjective ratings of sleep demonstrated clear-cut impairments of sleep in the insomniac group. Nocturnal IL-6 secretion was significantly increased (p<.05) in insomniac patients for the whole measurement period (mean area under the curve+/-SD: 27.94+/-14.15 pg/ml x 2h) compared to controls (16.70+/-7.64 pg/ml x 2h). Total IL-6 secretion correlated inversely with subjectively perceived sleep quality and amount of slow wave sleep in the insomniac patients. Amount of Wake Time correlated positively with IL-6 excretion in insomniacs. The results of the present study demonstrate significantly increased nocturnal IL-6 secretion in insomniacs. It might be speculated that chronic primary insomnia with polysomnographically documented sleep impairments activates the production of IL-6 analogous to sleep deprivation studies in healthy subjects. This might also implicate a higher risk for inflammatory and cardiovascular diseases in patients with chronic insomnia.

Riemann D. · Abteilung für Psychiatrie und Psychotherapie der Universitätsklinik Freiburg. · MMW Fortschr Med. · Pubmed #15968865 No free full text.

Abstract: Sleep disorders could be the symptoms of organic or non-organic conditions. The diagnostics comprises a detailed medical history of the patient complemented by a sleep diary, as well as organic medical and psychological/psychiatric examinations. For drug therapy benzodiazepine, antidepressants, neuroleptics, antihistamines, plant-based preparations and natural sleep-inducing substances such as L-tryptophan or melatonin are used. Nondrug strategies include sleep hygiene, stimulus control, sleep restriction and cognitive techniques. For sleep disturbances due to a psychological or organic disease, the primary condition must be treated.

Hornyak M, Riemann D, Voderholzer U. · Department of Psychiatry and Psychotherapy, University Hospital of Freiburg, Hauptstrasse 5, D-79104 Freiburg, Germany. · Sleep Med. · Pubmed #15511708 No free full text.

Abstract: BACKGROUND AND PURPOSE: Periodic leg movements in sleep (PLMS) are a common finding in various sleep disorders. Whether PLMS are an epiphenomenon or are causally related to the presence of sleep-wake disturbances is still being debated. We investigated the relationship of the occurrence of PLMS to patients' perception of sleep quality during a night of polysomnography in various sleep disorders. METHODS: The retrospective evaluation included PLMS recordings over two nights of 78 consecutive patients diagnosed with a restless legs syndrome, primary insomnia or insomnia associated with a psychiatric disorder. The subjects' perception of sleep during the polysomnography night was assessed by the subscale 'sleep quality' of the validated self-rating sleep questionnaire SFA (SFA-SQ). RESULTS: SFA-SQ scores correlated with the PLMS index (number of PLMS per hour of sleep) only in patients with restless legs syndrome during the first of the two nights investigated (r=-0.464, P<0.01). PLMS appear to have a low impact on the subjects' perception of sleep quality. The correlation of subjective sleep quality to PLMS index in the first of the two investigated nights in RLS patients may reflect an adaptation effect. CONCLUSION: The results of our study favor the hypothesis that PLMS most likely are not the primary cause of sleep disturbances in these patient groups.

Riemann D, Klein T, Rodenbeck A, Feige B, Horny A, Hummel R, Weske G, Al-Shajlawi A, Voderholzer U. · Department of Psychiatry and Psychotherapy, University Hospital of Freiburg, Hauptstrasse 5, 79104, Freiburg, Germany. · Psychiatry Res. · Pubmed #12467942 No free full text.

Abstract: The present study investigated evening and nocturnal serum cortisol and melatonin concentrations in patients with primary insomnia to test if this clinical condition is accompanied by an increase of cortisol secretion and a simultaneous decrease of nocturnal melatonin production. Ten drug-free patients (4 males, 6 females) with primary insomnia (mean age+/-S.D.: 39.2+/-9.1 years) and 10 age- and gender-matched healthy controls participated in the study. All subjects spent three consecutive nights in the sleep laboratory with polysomnography. Measurement of cortisol and melatonin (from 19:00 h to 09:00 h) was performed prior to and during the last laboratory night. Contrary to expectation, cortisol secretion did not differ between healthy controls and insomniac patients. On the other hand, nocturnal melatonin production was significantly diminished in insomniac patients. Polysomnographically determined sleep patterns, in contrast to subjective ratings of sleep, demonstrated only minor alterations of sleep in the insomniac group. The lack of increased cortisol secretion in the patients with primary insomnia indicates that results from studies on the biological consequences of experimental sleep loss in healthy subjects cannot be applied to primary insomnia in general, especially if there are only minor objective sleep alterations. In spite of the negligible objective sleep disturbances in the present sample, nocturnal melatonin production was reduced, which tentatively suggests a role for this hormone in primary insomniacs. The pathophysiological significance of this finding is, however, still a matter of debate.

Backhaus J, Junghanns K, Broocks A, Riemann D, Hohagen F. · Department of Psychiatry and Psychotherapy, University Hospital of Luebeck, Luebeck, Germany. · J Psychosom Res. · Pubmed #12217446 No free full text.

Abstract: OBJECTIVE: Psychometric evaluation of the Pittsburgh Sleep Quality Index (PSQI) for primary insomnia. METHODS: The study sample consisted of 80 patients with primary insomnia (DSM-IV). The length of the test-retest interval was either 2 days or several weeks. Validity analyses were calculated for PSQI data and data from sleep diaries, as well as polysomnography. To evaluate the specificity of the PSQI, insomnia patients were compared with a control group of 45 healthy subjects. RESULTS: In primary insomnia patients, the overall PSQI global score correlation coefficient for test-retest reliability was .87. Validity analyses showed high correlations between PSQI and sleep log data and lower correlations with polysomnography data. A PSQI global score > 5 resulted in a sensitivity of 98.7 and specificity of 84.4 as a marker for sleep disturbances in insomnia patients versus controls. CONCLUSION: The PSQI has a high test-retest reliability and a good validity for patients with primary insomnia.

Wittchen HU, Krause P, Höfler M, Pittrow D, Winter S, Spiegel B, Hajak G, Riemann D, Steiger A, Pfister H. · Institut für Klinische Psychologie und Psychotherapie der Technischen Universität Dresden und Max-Planck-Institut für Psychiatrie, Klin. Psychologie und Epidemiologie, München. · Fortschr Med Orig. · Pubmed #11935661 No free full text.

Abstract: AIM: To estimate the point prevalence of insomnia, recognition and prescription behavior in primary care. METHODS: Nationwide sample of 539 primary care settings along with their characterization (stage 1). Standardized assessment of all attenders (N = 19.155 patients) on the NISAS target day using a sleep questionnaire (PSQI) and additional questions to cover psychosocial and additional clinical variables. All patients were evaluated by the primary care doctors using a standardized clinical appraisal questionnaire, including a CGI-rating. RESULTS: Prevalence insomnia according to DSM-IV was 26.5%. Recognition of presence of any clinically significant sleep disorder was 72%, recognition of insomnia was poor 54.3%. 85.6% of insomnia patients were rated as chronic. Close to 50% of all insomnia cases did not receive a specific insomnia therapy. Herbals, followed by hypnotics and sedatives and antidepressants were the three most frequent treatments applied, psychotherapy was only seldomly indicated. DISCUSSION: NISAS provides for the first time nationally representative estimates of interventions for insomnia in primary care. The relatively low treatment rates and the high proportion of chronic patients receiving longterm prescription of benzodiazepines seem to be critical. Priorities for future agenda to improve this situation are discussed.

Riemann D, Feige B, Hornyak M, Koch S, Hohagen F, Voderholzer U. · Department of Psychiatry and Psychotherapy, University of Freiburg, Hauptstrasse 5, Germany. · Psychiatry Res. · Pubmed #11927137 No free full text.

Abstract: The application of the tryptophan depletion test is based on the assumption that the decrease of plasma or serum tryptophan concentration following the ingestion of a tryptophan-free amino acid drink reflects a central nervous effect on serotonin metabolism. In the present study the impact of tryptophan depletion on polysomnographically recorded sleep in patients with primary insomnia was studied. Fifteen patients with primary insomnia slept for four nights in the sleep laboratory. Prior to the fourth night the tryptophan depletion test was applied. Sleep EEG variables served as outcome parameters. Patients with primary insomnia, compared to baseline values showed a highly significant decrease of serum tryptophan concentrations after the amino acid drink. Concerning sleep parameters, stage 1 (% sleep period time=SPT) was increased, whereas stage 2 (% SPT) was decreased. Indices of phasic activity of rapid eye movement (REM) sleep (REM density) were increased after the tryptophan depletion compared to baseline. The results suggest a negative impact of tryptophan depletion on sleep continuity and a stimulating effect on phasic measures of REM sleep in patients with primary insomnia.