Moving beyond average values: assessing the night-to-night instability of sleep and arousal in DSM-IV-TR insomnia subtypes

Sleep. 2011 Apr 1;34(4):531-9. doi: 10.1093/sleep/34.4.531.


Study objectives: We explored differences between individuals with DSM-IV-TR diagnoses of primary insomnia (PI) and insomnia related to a mental disorder (IMD) by using serial measurements of self-reported sleep variables (sleep onset latency, SOL; wake after sleep onset, WASO; total sleep time, TST; sleep efficiency, SE), and visual analogue scale ratings of 2 forms of bedtime arousal (cognitive and emotional). Furthermore, we sought to examine the relationship between sleep and arousal within each diagnostic subgroup.

Design: Between-group and within-group comparisons.

Setting: Duke and Rush University Medical Centers, USA.

Participants: One hundred eighty-seven insomnia sufferers (126 women, average age 47.15 years) diagnosed by sleep specialists at 2 sleep centers as PI patients (n=126) and IMD patients (n=61).

Interventions: N/A.

Measurements and results: Multilevel models for sleep measures indicated that IMD displayed significantly more instability across nights in their TST (i.e., larger changes) than did PI patients. With respect to pre-sleep arousal, IMD patients exhibited higher mean levels of emotional arousal, as well as more instability on the nightly ratings of this measure. Within the PI group, correlational analyses revealed a moderate relationship between the 2 arousal variables and SOL (r values 0.29 and 0.26), whereas the corresponding correlations were negligible and statistically nonsignificant in the IMD group.

Conclusions: We found a number of differences on nighttime variables between those diagnosed with primary insomnia and those diagnosed with insomnia related to a mental disorder. These differences imply different perpetuating mechanisms involved in their ongoing sleep difficulties. Additionally, they support the categorical distinctiveness and the concurrent validity of these insomnia subtypes.

Keywords: DSM-IV-TR; arousal; concurrent validity; insomnia related to a mental disorder; instability; measurement; primary insomnia.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Arousal / physiology*
  • Diagnostic and Statistical Manual of Mental Disorders
  • Female
  • Humans
  • Male
  • Mental Disorders / complications
  • Mental Disorders / physiopathology
  • Middle Aged
  • Polysomnography
  • Psychiatric Status Rating Scales
  • Severity of Illness Index
  • Sleep / physiology*
  • Sleep Initiation and Maintenance Disorders / classification
  • Sleep Initiation and Maintenance Disorders / etiology
  • Sleep Initiation and Maintenance Disorders / physiopathology*
  • Surveys and Questionnaires
  • Time Factors