Ecological Momentary Assessment Ecological Momentary Assessment in Primary Insomnia in Primary Insomnia

Ecological Momentary Assessment ConferencePittsburgh, PAJuly 10, 2006

Daniel J. Buysse, M.D.Daniel J. Buysse, M.D.

Professor of PsychiatryProfessor of Psychiatry

University of Pittsburgh School of MedicineUniversity of Pittsburgh School of Medicine

Research diagnostic criteria for insomnia Research diagnostic criteria for insomnia disorderdisorder Edinger, Edinger, SLEEPSLEEP 2004; 27:1567-96 2004; 27:1567-96

A.A. The individual reports one or more of the following The individual reports one or more of the following sleep related complaints:sleep related complaints:

1.1. difficulty initiating sleepdifficulty initiating sleep

2.2. difficulty maintaining sleepdifficulty maintaining sleep

3.3. waking up too early, or waking up too early, or

4.4. sleep that is chronically nonrestorative or poor in qualitysleep that is chronically nonrestorative or poor in quality

B.B. The above sleep difficulty occurs despite adequate The above sleep difficulty occurs despite adequate opportunity and circumstances for sleep.opportunity and circumstances for sleep.

Research diagnostic criteria for insomnia Research diagnostic criteria for insomnia disorderdisorder Edinger, Edinger, SLEEPSLEEP 2004; 27:1567-96 2004; 27:1567-96

C.C. At least one of the following forms of daytime At least one of the following forms of daytime impairment related to the nighttime sleep impairment related to the nighttime sleep difficulty is reported by the individual:difficulty is reported by the individual:

1.1. Fatigue/ malaise;Fatigue/ malaise;

2.2. Attention, concentration, or memory impairment;Attention, concentration, or memory impairment;

3.3. Social/ vocational dysfunction or poor school performance;Social/ vocational dysfunction or poor school performance;

4.4. Mood disturbance/ irritability;Mood disturbance/ irritability;

5.5. Daytime sleepiness;Daytime sleepiness;

6.6. Motivation/energy/initiative reduction;Motivation/energy/initiative reduction;

7.7. Proneness for errors/accident at work or while driving;Proneness for errors/accident at work or while driving;

8.8. Tension headaches, and/or GI symptoms in response to Tension headaches, and/or GI symptoms in response to sleep loss;sleep loss;

9.9. Concerns or worries about sleep.Concerns or worries about sleep.

Consequences of insomnia Buysse, Primary Psychiatry, 2005;12(8):50-57

Decreased quality of life Decreased quality of life

Difficulty concentratingDifficulty concentrating

Memory problemsMemory problems

Increased absenteeismIncreased absenteeism

Decreased job performanceDecreased job performance

Increased incidence of psychiatric disorders,Increased incidence of psychiatric disorders,pain, poor healthpain, poor health

Increased risk of falls and hip fracturesIncreased risk of falls and hip fractures

Increased healthcare utilizationIncreased healthcare utilization

Ecological momentary Ecological momentary assessment of assessment of daytime symptoms in daytime symptoms in insomniainsomnia EcologicalEcological: Subjects : Subjects

studied in the environment studied in the environment they typically inhabitthey typically inhabit

MomentaryMomentary: Data : Data collection in near-collection in near-immediate state avoids immediate state avoids retrospective biasretrospective bias

AssessmentAssessment: Multiple : Multiple assessments per day assessments per day allow representative allow representative characterization of characterization of phenomena under study phenomena under study and permit assessment of and permit assessment of temporal variationtemporal variation

Examples of EMA for one week in insomnia patients

Concentration Mood Energy Alertness Overall

Day number

Ra

tin

g

GoalsGoals

Characterize waking symptoms in subjects with Characterize waking symptoms in subjects with Primary Insomnia (PI), using statistical Primary Insomnia (PI), using statistical techniques to analyze EMA datatechniques to analyze EMA data

Compare PI and Good Sleeper Controls (GSC)Compare PI and Good Sleeper Controls (GSC) Compare PI and GSC on “standard” Compare PI and GSC on “standard”

retrospective clinical scales and sleep diaryretrospective clinical scales and sleep diary Examine relationships between EMA ratings, Examine relationships between EMA ratings,

standard scales, sleep diarystandard scales, sleep diary

SubjectsSubjects

GeneralGeneral PI and GSC, 3:1 ratioPI and GSC, 3:1 ratio Age 20-50 years, men and womenAge 20-50 years, men and women Medical history, psychiatric history (SCID), sleep disorders Medical history, psychiatric history (SCID), sleep disorders

history, screening PSG (AHI, PLMAI < 15)history, screening PSG (AHI, PLMAI < 15)

PI (n = 47)PI (n = 47) DSM-IV Primary InsomniaDSM-IV Primary Insomnia PSQI PSQI ≥ 7≥ 7 No specific quantitative criteriaNo specific quantitative criteria

GSC (n = 18)GSC (n = 18) No sleep disorderNo sleep disorder PSQI ≤ 5PSQI ≤ 5

MeasuresMeasures

Retrospective questionnairesRetrospective questionnaires Inventory of Depressive Symptomatology (IDS) – Inventory of Depressive Symptomatology (IDS) –

sleep itemssleep items Beck Anxiety Inventory (BAI)Beck Anxiety Inventory (BAI) Penn State Worry Questionnaire (PSWQ)Penn State Worry Questionnaire (PSWQ) Hyperarousal Scale (HAS)Hyperarousal Scale (HAS) Multidimensional Fatigue Inventory (MFI), general Multidimensional Fatigue Inventory (MFI), general

fatiguefatigue Pittsburgh Sleep Quality Inventory (PSQI)Pittsburgh Sleep Quality Inventory (PSQI) Epworth Sleepiness Scale (ESS)Epworth Sleepiness Scale (ESS)

MeasuresMeasures

Pittsburgh Sleep Diary (PghSD)Pittsburgh Sleep Diary (PghSD) Total sleep timeTotal sleep time Sleep latencySleep latency Wake after sleep onsetWake after sleep onset Sleep efficiencySleep efficiency

Daytime Insomnia Symptom Scale (DISS)Daytime Insomnia Symptom Scale (DISS) 20 visual analog scales20 visual analog scales Presented 4 times per day: Wake up, noon, 6 p.m., Presented 4 times per day: Wake up, noon, 6 p.m.,

bed timebed time Presented on personal data assistantPresented on personal data assistant

StatisticsStatistics

Wilcoxon rank-sum test for retrospective, diary, Wilcoxon rank-sum test for retrospective, diary, and DISS dataand DISS data

Spearman rank-order correlationsSpearman rank-order correlations Functional principal components analysis Functional principal components analysis

(FPCA) for DISS data(FPCA) for DISS data Individual subjects’ data smoothed over time with Individual subjects’ data smoothed over time with

mixed-model B-spline regressions (3 quadratic B-mixed-model B-spline regressions (3 quadratic B-spline functions with equally-spaced knots)spline functions with equally-spaced knots)

FPCAFPCA Varimax rotationVarimax rotation

Functional principal component loading values Functional principal component loading values for items on the daytime symptoms in insomnia for items on the daytime symptoms in insomnia (DISS) scale in primary insomnia subjects(DISS) scale in primary insomnia subjects

Alert CognitionAlert Cognition

ForgetfulForgetful -0.792-0.792

Clear-headedClear-headed 0.7420.742

ConcentrateConcentrate 0.7420.742

EffortEffort -0.677-0.677

AlertAlert 0.4570.457

Positive MoodPositive Mood

RelaxedRelaxed 0.8080.808

EnergeticEnergetic 0.7060.706

CalmCalm 0.6870.687

HappyHappy 0.6580.658

EfficientEfficient 0.4270.427

Negative MoodNegative Mood

AnxiousAnxious 0.7500.750

StressedStressed 0.7030.703

TenseTense 0.6980.698

SadSad 0.6960.696

IrritableIrritable 0.5810.581

Sleepiness/FatigueSleepiness/Fatigue

FatiguedFatigued 0.9480.948

SleepySleepy 0.8800.880

ExhaustedExhausted 0.8410.841

Functional principal components analysis Functional principal components analysis of time series self-report dataof time series self-report data

- - - - Primary Insomnia (n=47) Good Sleeper Controls (n=18)

*p<.001 for each

Alert Cognition Negative Mood

Sleepiness/FatiguePositive Mood

Correlations between DISS factor scores, Correlations between DISS factor scores, retrospective psychological scales, and self-retrospective psychological scales, and self-report sleep measures in insomnia patients report sleep measures in insomnia patients (n=47)(n=47)

MeasureMeasure Alert Alert cognitioncognition

Negative Negative moodmood

Positive Positive moodmood

Sleepiness/Sleepiness/fatiguefatigue

Retrospective Retrospective psychological scalespsychological scales

Inventory of Depressive Inventory of Depressive SymptomatologySymptomatology

*-.32*-.32 **.43**.43 *-.30*-.30 .25.25

Multidimensional Fatigue Multidimensional Fatigue InventoryInventory

-.26-.26 .25.25 *-.35*-.35 ***.53***.53

Sleep diarySleep diary

Sleep latency (minutes)Sleep latency (minutes) *-.35*-.35 *.30*.30 -.23-.23 .26.26

Sleep Efficiency (%)Sleep Efficiency (%) .16.16 -.09-.09 *.30*.30 **-.39**-.39

* p<.05 ** p<.01 ***p<.001* p<.05 ** p<.01 ***p<.001

ConclusionsConclusions

EMA scales correspond to commonly-reported EMA scales correspond to commonly-reported waking symptom dimensions in PIwaking symptom dimensions in PI

EMA indicates differences between PI and GSCEMA indicates differences between PI and GSC LevelLevel of symptoms of symptoms Diurnal patternsDiurnal patterns of symptoms of symptoms

May provide clues to pathophysiology of daytime May provide clues to pathophysiology of daytime dysfunction in insomniadysfunction in insomnia

[[1818F] deoxyglucose PET during a.m. and p.m. F] deoxyglucose PET during a.m. and p.m. wakefulness in healthy adultswakefulness in healthy adults Buysse, Buysse, SleepSleep, 2004; 27:1245-54, 2004; 27:1245-54

Midbrain reticularformation/ Raphe

Pontine reticularformation

Posterior hypothalamus

L Locuscoeruleus

R Locuscoeruleus

Correlations between regional glucose Correlations between regional glucose metabolism and DISS factorsmetabolism and DISS factors

A. Alert cognition positive correlations

B. Sleepiness/Fatigue negative correlations

Correlations between regional glucose Correlations between regional glucose metabolism and DISS factorsmetabolism and DISS factors

A. Positive Affect positive correlations

B. Positive Affect positive correlations

C. Negative Affect negative correlations