Search

Three quarters of patients suffering from a mental illness reported sleep complaints. Both the physiological and psychological aspects of sleep reflect changes in patients suffering from various types of emotional disorders. Having demonstrated at both the subjective and objective level that the sleep of anxious subjects is discriminable from the nonanxious, it was of interest to see if the degree of anxiety covaries with the degree of sleep disturbance in any of the sleep parameters, both subjective and objective. In a series of reports of the study of sleep and dream characteristics of a group of patients with chronic delayed post-traumatic stress disorder sufferers, it was found that their sleep and dreams were indeed altered. Changes in the sleep patterns, psychologically and physiologically, of the depressed occur with improvement in the depression. Of all the psychopathologies, schizophrenia has been the major enigma to sleep researchers. The psychobiology of schizophrenia, from the perspective of sleep, remains to be understood.

A number of behavioral, social, biological, and cultural factors are associated with suicide. However, the ability to predict an imminent suicide attempt remains problematic. Prior studies indicate that the manifest dream content of depressed, non-suicidal patients differs from that of depressed, suicidal patients. The dream imagery of depressed, suicidal patients contains themes of death, dying, violence, and departure. The dream imagery of depressed, non-suicidal patients contains themes of rejection, helplessness, hopelessness, humiliation, failure, and loss. In the present study, the dream reports of 52 depressed patients were collected and rated for various themes. Patients were divided into three groups: Depressed and non-suicidal; Depressed, with suicidal ideation; Depressed, with suicidal ideation and/or attempt(s). Themes of death and/or dying, and to a lesser extent, themes of violence, injury, and/or murder occurred with greater frequency in the dream reports of depressed patients with suicidal ideation and/or attempts, than in the dream reports of depressed patients without suicidal ideation or behavior. These observations correspond with the prevailing psychodynamic explanation of suicide; namely, that it is a murderous attack on the self that is identified with hated internalized objects.

The potential shortage of psychiatrists over the next 5 - 10 years has focused attention on the need to recruit more IMGs to fill the needs rather than use nurse practitioners or physician assistants. IMGs make up about 1/3 of first year psychiatry residents. These individuals have been found to provide services to the poor, the elderly and the psychotic. The quality of their medical work has been found to be satisfactory. The training needs of these physicians require an understanding on the part of their teachers that they come from cultures with different values that we have. The extended families of these primarily Asian residents clash with our strong commitment to individualism. It leads to a We-self rather than our I-Self. This difference coupled with the stress of leaving to come to a new culture is a great stress. Their exposure to psychiatry has been limited. They request and need more interview demonstration and practice, ore feedback and examinations. They should have help in accent reduction. They should be exposed to the working of the hospital by sitting on departmental and hospital committees. The faculty should extend their social opportunities and work as mentors on joint projects. Courses on the history of American culture should be taught. Psychotherapy for them should be encouraged as well as teaching medical ethics. They must become the major educational concern for the department that they are in.

The values of American culture have changed and this has led since 1970 to a competition with traditional medical values. The social forces that have stirred a reconsideration of core medical values come from 1. economic, 2. institutional and 3. life style sources and is related to efforts by non-service providers to gain profits from medical services and the attempts by both governmental and non-governmental sources to control the cost of medical care. The actions of physicians will be assessed based on how well their behavior conforms to the ethical precepts of the profession. Being instructed in what the ethical precepts are and in how they were derived should contribute to establishing the expectations for what is expected of the physician. In order to delineate medical professionalism for the practitioner and the student we will explore: 1) the sources from which medical professionalism were derived, 2) the attempts to define medical professionalism, 3) conceptual approaches to medical professionalism, 4) the process of change in the scope of medical professionalism in the 20 th century, and 5) attempts to teach medical professionalism.

International medical graduate (IMG) physicians are vital to the physician workforce in the United States, and over the past few decades have become especially important in the provision of psychiatric care in this country. IMG physicians have assumed crucial roles in caring for the underserved, and they have had greater opportunities in public psychiatry than in other areas of the field. In this chapter, key historical patterns in medical training in the United States are outlined. Medical training in India is described to illustrate issues experienced by medical graduates not born in the United States. It is suggested that IMG physicians are collaborators who bring wisdom, expertise, effort, and valuable traditions, and yet IMG physicians have often faced prejudice and obstacles to their professional advancement. It is hoped that IMG physicians in the future will be more respectfully embraced and will have robust professional opportunities in the health system of the United States and other economically established countries.

The heterogeneity in the cultural, linguistic, and medical educational background of international medical graduate (IMG) physicians in psychiatry poses significant challenges in assessing their training needs. This chapter addresses the complex determination of training needs and their recommended solutions. To that end, inter-group differences within the IMG physician spectrum are discussed, with an emphasis on the imperatives within each culture. The recent literature on training needs for IMG physicians was reviewed and the following needs were identified as most relevant (in descending order): communication and language skills, medical/pharmacologic knowledge, dealing with social isolation, other acculturation issues, adequacy of supervision, psychosocial/patient management focus, cultural diversity training, understanding the health care systems, understanding the hospital culture, and medical documentation. This chapter highlights the role of psychotherapy training as an acculturative experience, along with the importance of a program development paradigm for needs evaluation and training implementation. Specific recommendations will be listed to assist training directors and IMG physicians in this crucial training area.

Positive airway pressure (PAP) devices are used to treat patients with sleep related breathing disorders (SRBD) including obstructive sleep apnea (OSA). Currently, PAP devices come in three forms: (1) continuous positive airway pressure (CPAP), (2) bilevel positive airway pressure (BPAP), and (3) automatic self-adjusting positive airway pressure (APAP). After a patient is diagnosed with OSA, the current standard of practice involves performing full, attended polysomnography during which positive pressure is adjusted to determine optimal pressure for maintaining airway patency. This titration is used to find a fixed single pressure for subsequent nightly usage. A task force of the Standards of Practice Committee of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Standards of Practice Committee developed these practice parameters as a guideline for using CPAP and BPAP appropriately (an earlier review and practice parameters for APAP was published in 2002). Major conclusions and current recommendations are as follows: 1) A diagnosis of OSA must be established by an acceptable method. 2) CPAP is effective for treating OSA. 3) Full-night, attended studies performed in the laboratory are the preferred approach for titration to determine optimal pressure; however, split-night, diagnostic-titration studies are usually adequate. 4) CPAP usage should be monitored objectively to help assure utilization. 5) Initial CPAP follow-up is recommended during the first few weeks to establish utilization pattern and provide remediation if needed. 6) Longer-term follow-up is recommended yearly or as needed to address mask, machine, or usage problems. 7) Heated humidification and a systematic educational program are recommended to improve CPAP utilization. 8) Some functional outcomes such as subjective sleepiness improve with positive pressure treatment in patients with OSA. 9) CPAP and BPAP therapy are safe; side effects and adverse events are mainly minor and reversible. 10) BPAP may be useful in treating some forms of restrictive lung disease or hypoventilation syndromes associated with hypercapnia.

Characterization of excessive sleepiness is an important task for the sleep clinician, and assessment requires a thorough history and in many cases, objective assessment in the sleep laboratory. These practice parameters were developed to guide the sleep clinician on appropriate clinical use of the Multiple Sleep Latency Test (MSLT), and the Maintenance of Wakefulness Test (MWT). These recommendations replace those published in 1992 in a position paper produced by the American Sleep Disorders Association. A Task Force of content experts was appointed by the American Academy of Sleep Medicine to perform a comprehensive review of the scientific literature and grade the evidence regarding the clinical use of the MSLT and the MWT. Practice parameters were developed based on this review and in most cases evidence based methods were used to support recommendations. When data were insufficient or inconclusive, the collective opinion of experts was used to support recommendations. These recommendations were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. The MSLT is indicated as part of the evaluation of patients with suspected narcolepsy and may be useful in the evaluation of patients with suspected idiopathic hypersomnia. The MSLT is not routinely indicated in the initial evaluation and diagnosis of obstructive sleep apnea syndrome, or in assessment of change following treatment with nasal continuous positive airway pressure (CPAP). The MSLT is not routinely indicated for evaluation of sleepiness in medical and neurological disorders (other than narcolepsy), insomnia, or circadian rhythm disorders. The MWT may be indicated in assessment of individuals in whom the inability to remain awake constitutes a safety issue, or in patients with narcolepsy or idiopathic hypersomnia to assess response to treatment with medications. There is little evidence linking mean sleep latency on the MWT with risk of accidents in real world circumstances. For this reason, the sleep clinician should not rely solely on mean sleep latency as a single indicator of impairment or risk for accidents, but should also rely on clinical judgment. Assessment should involve integration of findings from the clinical history, compliance with treatment, and, in some cases, objective testing using the MWT. These practice parameters also include recommendations for the MSLT and MWT protocols, a discussion of the normative data available for both tests, and a description of issues that need further study.

International medical graduates (IMGs) currently make up about 25% of physicians practicing in the US. IMGs and U.S. medical school graduates (USMGs) have a great deal in common. The quality of the medical skills of more recent IMGs has improved as measured by the scores they obtain on the clinical skills assessment examination and has begun to approach that of USMGs, 89% compared to 80% (Whelan, Gary, Kostis, Boulet, & Hallock, 2002). In clinical practice, IMGs provide services comparable in effectiveness to USMGs (Norcini et al., 2010). However, the specific educational needs of IMGs must be recognized by training programs. IMGs face a series of concurrent issues having to do with immigration (Akhtar, 1999), which may result in loneliness and social isolation, a decrease in social status with diminishment of self-esteem, concerns related to the family left behind, and the impact of migration on the family they may have brought with them. Some IMGs are also concerned about the vagaries of their visa status. Group and individual resident social interaction with faculty is enormously valuable in reducing the sense of isolation. The central role of language and culture lies at the heart of the challenges that IMGs face in psychiatric training in the American context, particularly in learning psychological theory and therapy. Without mastery of the dominant language, both formal and informal (i.e., slang and idioms), IMGs may have difficulty understanding and being understood by their patients and teachers. In some settings, IMG psychiatric residents have asked for more intensive training including more demonstrations of interviewing, opportunities for oral presentations, and examinations and feedback. Fully 41% of psychiatric residents in the US are from Asia (Gangure, 2002) and their values and conceptions of personhood may be different from those

Background Psychiatric patients often have residual intractable insomnia as a serious problem. Method Forty-eight psychiatrically ill patients (DSM-IV diagnoses) who had failed to respond to medicinal treatment for chronic insomnia were referred for and completed behavioral therapy as an adjunct to the pharmacologic treatment of their insomnia. The behavioral treatments included structured sleep hygiene, progressive muscle relaxation, stimulus control, and sleep restriction. The treatment program was accomplished in 6 sessions over 2 months. Follow-up evaluations were completed at 2, 6, and 12 months from the beginning of the treatment program. The outcome of the treatment program was evaluated in terms of the change in (1) self-reported specific sleep parameters, (2) self-ratings of sleep-related day-time state, (3) self-rating of quality of sleep, (4) the use of sleep medication, and (5) the therapist's global rating of improvement. Results There was a statistically significant change from the baseline in all self-reported specific sleep parameters after 2 months that was sustained after 6 and 12 months. Sleep-related characteristics of daytime state showed statistically significant changes after 2 and 6 months that were maintained after 12 months. Sleep quality had a statistically significant change after 2 months, continued to improve statistically after 6 months, and was maximum after 12 months. Over half the patients (52.7%; 20 of 38) either reduced their sleep medication by half or stopped it completely. The therapist's global rating showed an improvement in 29.2% (N = 14) of patients after 2 months, 56.2% (N = 27) after 6 months, and 68.7% (N = 33) after 12 months. Conclusion The use of concomitant behavioral and pharmacologic treatment of chronic insomnia in psychiatrically ill patients results in improving sleep and sleep-related state and reduces the risk of return of insomnia for 10 months after finishing active treatment.

Although subjective evidence suggests that patients with burns are deprived of sleep, previous clinical studies have been limited to observational data and have not to date included electroencephalographic or polysomnographic recordings. The purpose of this study was to characterize the sleep pattern of patients suffering from thermal injury. Biweekly 24-hour polysomnographic measurements (electromyography, electrooculography, and electroencephalography) were performed with 12 leads. This measuring permitted continuous recording of intrinsic electrical activity in skeletal muscles via chin electrodes, eye movement via outer canthal electrodes, and brain wave activity with the other bipolar electrodes. Determinations were obtained on 11 patients with thermal injuries for a total of 43 24-hour periods. The patients had a mean age of 8.31 +/- 1.5 years (range 1.4 to 16 years), a mean total body surface area burn of 55.1% +/- 16.5% (range 17.5% to 90.5%), and a mean full-thickness burn of 48.5% +/- 8.1% (range 10.5% to 90.5%). Although mean total sleep time was seemingly adequate (625.1 +/- 31.6 min/patient/24 hrs), large aberrations in sleep stage distribution were noted. Significant decreases in stage 3 + 4 and in rapid eye movement (deep sleep) and increases in stages 1 and 2 (light sleep) were noted, suggesting a cycling back to stages 1 or 2 after disruption of sleep. Overall, in 43 runs 40% of the subjects were completely lacking stage 3 + 4, and 19% were missing rapid eye movement during an entire 24-hour run.(ABSTRACT TRUNCATED AT 250 WORDS)

This review begins with the history of the events starting with the death of Libby Zion that lead to the Bell Commission, that the studied her death and made recommendations for improvement that were codified into law in New York state as the 405 law that the ACGME essentially adopted in putting a cap on work hours and establishing the level of staff supervision that must be available to residents in clinical situations particularly the emergency room and acute care units. A summary is then provided of the findings of the laboratory effects of total sleep deprivation including acute total sleep loss and the consequent widespread physiologic alterations, and of the effects of selective and chronic sleep loss. Generally the sequence of responses to increasing sleep loss goes from mood changes to cognitive effects to performance deficits. In the laboratory situation, deficits resulting from sleep deprivation are clearly and definitively demonstrable. Sleep loss in the clinical situation is usually sleep deprivation superimposed on chronic sleep loss. An examination of questionnaire studies, the literature on reports of sleep loss, studies of the reduction of work hours on performance as well as observational and a few interventional studies have yielded contradictory and often equivocal results. The residents generally find they feel better working fewer hours but improvements in patient care are often not reported or do not occur. A change in the attitude of the resident toward his role and his patient has not been salutary. Decreasing sleep loss should have had a positive effect on patient care in reducing medical error, but this remains to be unequivocally demonstrated.

Dr Kripke’s commentary “Non Nocere, If You Really Care” [1] on my paper “Hypnotic Medication in the Treatment of Chronic Insomnia” [2], provides an outstanding example of civil discourse in exploring an important professional difference of opinion: the role, if any, of hypnotics in the treatment of chronic insomnia. His comments underscore that one can disagree without being disagreeable, a point some of our colleagues have yet to learn [3]. This does not mean that Dr Kripke is dispassionate in his concern about the dangers of using hypnotics over long periods of time. On the contrary, he urges that the practice stop until a more definitive study of the problem is undertaken to establish the risks and benefits, if any, of prescribing hypnotic medications long-term [4]. Unfortunately, I am constrained by editorial considerations to respond only to his commentary on my review [2] and not on his review itself [4] or his two earlier papers [5, 6] all of which I would urge the interested reader to examine. I want to state at the outset that Dr Kripke’s major recommendation that we undertake long-term controlled trials of hypnotic efficacy and safety is a recommendation with which I would, of course, agree. I do not believe that my concern about whether such trials could be successfully carried out reflects a hopelessness on my part. Rather, it is the recognition of the difficulties likely to be encountered and the desirability of considering additional strategies to monitor effectiveness and side effects. The development of large, systematic databases, as has been recommended recently [7] as appropriate to study some types of health problems, should be applied to studying the long-term use of hypnotics in chronic insomnia. Dr Kripke recognises the problems the clinician has in treating patients with profound insomnia. In the clinical illustration in my article [2], Ms B., an 87-year-old woman, had been on benzodiazepines for 15 years and has anxiety and a sleep complaint. She was urged by her physician to reduce her benzodiazepine as he was concerned that it might be harming her health. Ms B. had had her symptoms of anxiety and poor sleep since young adulthood. With her medication reduced by 75%, she described her

1. Sleep and gastrointestinal functioning 2. Sleep and respiratory disorders 3. Sleep and coronary artery disease 4. Sleep and genitourinary systems 5. Sleep and depression: A functional neuroimaging perspective 6. Sleep alterations in schizophrenia 7. Sleep and neurological disorders 8. Behavioural interventions for sleep disorders 9. Medication effects on sleep 10. Sleep and personality disorders 11. A review of dreaming by psychiatric patients 12. Sleep and headache disorders 13. Sleep and infection 14. Narcolepsy 15. Sleep and stress 16. Sleep and attachment disorders in children 17. Animal modes of insomnia 18. Sleep deprivation as an antidepressant 19. Fibromyalgia and the neurobiology of sleep

This review summarizes the available knowledge on the phenomenology of posttraumatic dreams. Posttraumatic nightmares are reported by up to 70% of individuals suffering from posttraumatic stress disorder (PTSD). An extensive review of polysomnographic studies suggests that neither this high incidence nor the occurrence of posttraumatic nightmares throughout the sleep cycle can be explained by altered REM sleep parameters. The assumption that a reduction of dream recall may serve as a coping mechanism in PTSD patients is questionable. About 50% of posttraumatic dreams comprise exact replications of the traumatic events. Therefore dreams in PTSD do not have stereotypical content. Data characterizing non-replicative posttraumatic dreams and indicating a change in dream content over time must be considered preliminary. Occurrence of posttraumatic dreams is associated with psychopathological developments. Imagery Rehearsal Therapy has repeatedly been proven to be a valuable tool in treating patients suffering from posttraumatic dream disturbance. A deeper knowledge of posttraumatic dreams is essential for any theory of PTSD as well as for a better understanding of the overall function of dreaming.

Suggestions have been made on how to meet the educational challenges of international medical graduates (IMGs) such as learning to do psychodynamic psychotherapy. These suggestions include providing more structured instruction with explicit feedback. More demonstration of interviewing by faculty and more opportunity to do practice interviews are necessary. Language, slang, and accent reduction training needs to be incorporated into the training program. Courses in American culture are essential for IMGs. Focusing on board preparation with special courses might well improve pass rates. Including psychological theory from the start of the residency and discussing the psychological aspects of the doctor-patient and staff encounters in many clinical settings will place the psychological issues on a sounder footing. IMGs could benefit from having a mentor available to discuss both personal and professional issues.

These practice parameters are an update of the previously published recommendations regarding use of oral appliances in the treatment of snoring and Obstructive Sleep Apnea (OSA). Oral appliances (OAs) are indicated for use in patients with mild to moderate OSA who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP. Until there is higher quality evidence to suggest efficacy, CPAP is indicated whenever possible for patients with severe OSA before considering OAs. Oral appliances should be fitted by qualified dental personnel who are trained and experienced in the overall care of oral health, the temporomandibular joint, dental occlusion and associated oral structures. Follow-up polysomnography or an attended cardiorespiratory (Type 3) sleep study is needed to verify efficacy, and may be needed when symptoms of OSA worsen or recur. Patients with OSA who are treated with oral appliances should return for follow-up office visits with the dental specialist at regular intervals to monitor patient adherence, evaluate device deterioration or maladjustment, and to evaluate the health of the oral structures and integrity of the occlusion. Regular follow up is also needed to assess the patient for signs and symptoms of worsening OSA. Research to define patient characteristics more clearly for OA acceptance, success, and adherence is needed.

Chronic primary insomnia is a recurrent condition that negatively effects the daily functioning of patients diminishing the quality of their lives. It is associated with and in some situations is a risk factor in both psychiatric (depression) and physical illness (cardio-vascular). Treatment effectiveness in insomnia has been shown short term for both drug (benzodiazepine and benzodiazepine agonists) and behavioral treatment. Expert opinion has strongly advised against long term drug treatment because of concerns about residual sedative effects, memory impairment, falls, respiratory depression, rebound insomnia, medication abuse, dose escalation, dependency and withdrawal difficulties, and an increased risk of death possibly associated with the current hypnotic medications. Many of these concerns could be made against using these agents at all. Worries about these potential problems are challenged by the widespread clinical practice of using hypnotic drugs long term without any of these difficulties developing and with patients who feel their sleep and daily function is improved with the nightly use of their sleeping pill. The ability to mount a randomized, placebo controlled, parallel group, double blind trial of hypnotic medication in primary insomnia may not be possible. We may have to develop large systematic clinical databases, a number of case series in effect, to monitor both emergent symptoms and possible clinical effectiveness. There is the additional concern that there is a reluctance to examine the long — term drug treatment of insomnia. This reluctance may reflect a negative moral judgement about treating primary insomnia with drugs, a sort of “PharmacologicalCalvinism”, rather than just a data based judiciousness.

These practice parameters are an update of the previously-published recommendations regarding the indications for polysomnography and related procedures in the diagnosis of sleep disorders. Diagnostic categories include the following: sleep related breathing disorders, other respiratory disorders, narcolepsy, parasomnias, sleep related seizure disorders, restless legs syndrome, periodic limb movement sleep disorder, depression with insomnia, and circadian rhythm sleep disorders. Polysomnography is routinely indicated for the diagnosis of sleep related breathing disorders; for continuous positive airway pressure (CPAP) titration in patients with sleep related breathing disorders; for the assessment of treatment results in some cases; with a multiple sleep latency test in the evaluation of suspected narcolepsy; in evaluating sleep related behaviors that are violent or otherwise potentially injurious to the patient or others; and in certain atypical or unusual parasomnias. Polysomnography may be indicated in patients with neuromuscular disorders and sleep related symptoms; to assist in the diagnosis of paroxysmal arousals or other sleep disruptions thought to be seizure related; in a presumed parasomnia or sleep related seizure disorder that does not respond to conventional therapy; or when there is a strong clinical suspicion of periodic limb movement sleep disorder. Polysomnography is not routinely indicated to diagnose chronic lung disease; in cases of typical, uncomplicated, and noninjurious parasomnias when the diagnosis is clearly delineated; for patients with seizures who have no specific complaints consistent with a sleep disorder; to diagnose or treat restless legs syndrome; for the diagnosis of circadian rhythm sleep disorders; or to establish a diagnosis of depression.

Dopaminergic agents, particularly dopamine agonists, have been used with increasing frequency in the treatment of restless legs syndrome and periodic limb movement disorder. These evidence-based practice parameters are complementary to the Practice Parameters for the Treatment of Restless Legs Syndrome and Periodic Limb Movement Disorder, published in 1999. These practice parameters were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. Recommendations are based on the accompanying comprehensive review of the medical literature regarding the dopaminergic treatment of restless legs syndrome (RLS) and periodic limb movement disorder (PLMD), which was developed by a task force commissioned by the American Academy of Sleep Medicine. The following recommendations serve as a guide to the appropriate use of dopaminergic agents in the treatment of RLS and PLMD. Levodopa with decarboxylase inhibitor, and the dopaminergic agonists pergolide, pramipexole, and ropinirole are effective in the treatment of RLS and PLMD. Other dopamine agonists (talipexole, cabergoline, piribidel, and alpha-dihydroergocryptine) and the dopaminergic agents amantadine and selegiline may be effective in the treatment of RLS and PLMD, but the level of effectiveness of these medications is not currently established. Lastly, no specific recommendations can be made regarding dopaminergic treatment of children or pregnant women with RLS or PLMD.

Actigraphy is a method used to study sleep-wake patterns and circadian rhythms by assessing movement, most commonly of the wrist. These evidence-based practice parameters are an update to the Practice Parameters for the Use of Actigraphy in the Clinical Assessment of Sleep Disorders, published in 1995. These practice parameters were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. Recommendations are based on the accompanying comprehensive review of the medical literature regarding the role of actigraphy, which was developed by a task force commissioned by the American Academy of Sleep Medicine. The following recommendations serve as a guide to the appropriate use of actigraphy. Actigraphy is reliable and valid for detecting sleep in normal, healthy populations, but less reliable for detecting disturbed sleep. Although actigraphy is not indicated for the routine diagnosis, assessment, or management of any of the sleep disorders, it may serve as a useful adjunct to routine clinical evaluation of insomnia, circadian-rhythm disorders, and excessive sleepiness, and may be helpful in the assessment of specific aspects of some disorders, such as insomnia and restless legs syndrome/periodic limb movement disorder. The assessment of daytime sleepiness, the demonstration of multiday human-rest activity patterns, and the estimation of sleep-wake patterns are potential uses of actigraphy in clinical situations where other techniques cannot provide similar information (e.g., psychiatric ward patients). Superiority of actigraphy placement on different parts of the body is not currently established. Actigraphy may be useful in characterizing and monitoring circadian rhythm patterns or disturbances in certain special populations (e.g., children, demented individuals), and appears useful as an outcome measure in certain applications and populations. Although actigraphy may be a useful adjunct to portable sleep apnea testing, the use of actigraphy alone in the detection of sleep apnea is not currently established. Specific technical recommendations are discussed, such as using concomitant completion of a sleep log for artifact rejection and timing of lights out and on; conducting actigraphy studies for a minimum of three consecutive 24-hour periods; requiring raw data inspection; permitting some preprocessing of movement counts; stating that epoch lengths up to 1 minute are usually sufficient, except for circadian rhythm assessment; requiring interpretation to be performed manually by visual inspection; and allowing automatic scoring in addition to manual scoring methods.

Chronic primary insomnia is a recurrent condition that negatively effects the daily functioning of patients, diminishing the quality of their lives. It is associated with, and in some situations, is a risk factor in both psychiatric (depression) and physical (cardiovascular) illness. Treatment effectiveness has been shown in the short term for both drug (benzodiazepine and benzodiazepine agonists) and behavioral treatment. Expert opinion has strongly advised against long-term drug treatment because of concerns about residual sedative effects, memory impairment, falls, respiratory depression, rebound insomnia, medication abuse, dose escalation, dependency and withdrawal difficulties, and an increased risk of death possibly associated with the current hypnotic medications. Many of these concerns could be made against using these agents at all. Worries about these potential problems are challenged by the widespread clinical practice of using hypnotic drugs long-term without any of these difficulties developing and with patients who feel their sleep and daily function function is improved with the nightly use of their sleeping pill. The ability to mount a randomized, placebo-controlled, parallel group, double-blind trial of hypnotic medication in primary insomnia may not be possible. We may have to develop large systematic clinical databases, a number of case series in effect, to monitor both emergent symptoms and possible clinical effectiveness. There is the additional concern that there is a reluctance to examine the long-term drug treatment of insomnia. This reluctance may reflect a negative moral judgement about treating primary insomnia with drugs, a sort ofpharmacological Calvinism, rather than just a data based judiciousness.

International medical graduates (IMGs) constitute a significant proportion of the psychiatric workforce in the United States. Observership programs serve an important role in preparing IMGs for U.S. residency positions; yet there are limited resources with information available on establishing these observerships, and none specific to psychiatry. In this article, authors present a roadmap for observership programs in psychiatry for IMGs. This article draws on the experience of the IMG committee of the Group for Advancement of Psychiatry in establishing observership programs. Authors highlight the benefits of observership programs to IMGs, psychiatry departments, and the U.S. medical system as a whole. The different components of an observership program are presented, along with core competencies that need to be acquired. The authors discuss challenges that observership programs may encounter as well as recommendations for overcoming them. Observership programs provide a unique opportunity to integrate IMGs into the U.S. medical system. This article provides a framework for establishing such programs in a way that will optimize their benefits and avoid potential pitfalls. Drs. Hamoda and Sacks contributed equally to this article and are hence co-1st authors.

The present study evaluated the efficacy of 25 mg of quazepam, a new benzodiazepine hypnotic, in a population of chronic insomniacs. The results indicate that a single dose (25 mg) administered for one night was efficacious when measured both objectively by polysomnographic recording and subjectively by questionnaire with no reported side-effects. The change in the objective measures paralleled the direction of change in subjective measures. Sleep efficiency and sleep maintenance were improved without EEG changes in Stages 2, 3-4, and REM. Further study is needed to evaluate the effects of chronic administration of different doses of quazepam in chronic insomniacs.

Repetitive traumatic dreams remain a curiosity in our working with patients. If dreams have a sleep protecting or problem solving function, the dream that does not resolve but repeats and that disturbs rather than protects sleep remains an important clinical problem. We see in individual patient experiences and in civilian disasters samples of individuals who are unable to return their dream life to a condition in which it no longer repeats or disturbs their sleep. Clearly the recent experience of combat survivors of Vietnam becomes a major concern.

Scant attention has been paid to the objective evaluation of insomnia as a function of age, particularly with reference to increased drug sensitivity and resulting loss in balance performance. Therefore, the electroencephalographic sleep and the balance-board performance of 10 young and 12 geriatric insomniacs were studied under baseline and hypnotic drug (ketazolam) conditions. In terms of objectively measured sleep, the geriatric insomniacs had worse sleep on every dimension except sleep latency and percentage of stage-2 sleep. These differences between aged and young insomniacs, however, were no greater than might be expected as a function of normal aging. Drug-age interactions indicated that ketazolam differentially increased sleep efficiency, decreased the percentage of REM sleep, and eliminated any learning improvement on the balance board in geriatric versus young insomniacs. The findings indicate that the geriatric subjects were more sensitive to the hypnotic drug, in that their sleep improved to a greater extent. However, an important loss in balance performance was also observed.

The present study provided polysomnographic corroboration of the frequently reported rela- tionship between anxiety and subjective sleep disturbance. When compared to normals, anxious individuals were found to have significantly less sleep period time, total sleep time, percent stage REM and percent stage 4; shorter latency to stage REM; and greater percent stage 1. Partial correlations (holding depression constant) showed significant positive relationships between anxiety rating and number of awakenings, latency to stage 1, and percent stage 2. A significant negative relationship was found between anxiety and percent stage 4, and a nonsignificant negative trend was found between anxiety and latency to stage REM. Overall there was a tendency toward less sleep and lighter sleep in subjects with anxiety, thus validating subjective reports. The decreased latency to stage REM and its negative relation to anxiety, raised the possibility that this variable may not be specifically indicative of depression.

Disturbances of sleep are extremely common in the general population. Because of the large number of people seeking treatment for these disturbances, we opened a sleep clinic at the University of Cincinnati, primarily for the diagnosis and treatment of these disorders.1 A secondary function of the clinic was to help us gain information that would enhance our understanding of the various sleep disorders and permit us to evaluate the different treatment modalities for the different sleep disorders. The most common complaint of people seeking treatment at the clinic was insomnia. The present report is an attempt to provide a summary of some of our observations about the nature of insomnia. The data base for the present report consists of the information we gathered on the first 54 insomniac patients we saw at the Sleep Clinic. The data will be presented under several categories: demographic information, nature of sleep complaint, sleep laboratory observations, psychological testing, general health, and the subjective evaluation of sleep.

Two consecutive nights of flurazepam at each of 15, 26, and 45 mg were compared to placebo in a Latin-square double-blind crossover design using 24 healthy young-adult males. Flurazepam had significant hypnotic effects on objective and subjective measures of efficacy: shorter sleep latency, longer sleep time, and fewer awakenings. It also induced morning sedation along with decrements in cognitive performance. Flurazepam had dose-related impacts on both human and computer-scored EEG-EOG parameters: less stages 3 + 4 and decreased EEG delta, less stage 1 REM and decreased REM density, more stage 2 and increased EEG spindling. Also, EEG alpha and movement artifact were decreased and EEG beta was increased. Only a few of the EEG-EOG variables and none of the subjective indices had cumulative changes on the two drug nights. Stage shifting was unaffected at the two lower doses on the first night but decreased at all three dose levels on the second night; percent stages 3 + 4 was unaffected on the first night but decreased at all dose levels on the second night. The rate of delta waveform activity was also diminished by a greater amount on the second night. This study conclusively established that flurazepam affects the EEG-EOG architecture of sleep on each of the first two nights of administration.

Seventeen (seven mild and ten severe) chronic brain syndrome patients were tested in the sleep laboratory for dream recall and content. The mildly organic patients had 57 per cent recall while the severely organic patients had 35 per cent recall. We also studied four aged severely organic patients. These patients showed a recall rate of 8 per cent. The difference between the recall rates in mildly and severely organic middle-aged patients was not statistically significant. The difference between the recall rates of the aged severely organic patients and either or both of the middle-aged groups was statistically significant (p < .001). In addition, we found dream content differences between the mildy and severely organic middle-aged groups and between the combined group and normal young men.

To standardize data collection and processing procedures, three Veterans Administration sleep laboratories established standard procedures “on paper,” implemented them in a study, and assessed scoring agreement for sleep EEG-EOG recordings. The first phase of the study resulted in a detailed written description of all basic procedures. For the second, each laboratory evaluated 6 mentally and physically healthy males on three consecutive nights. Overall scoring agreement was about 90%. It was at least 89% between pairs of laboratories for stage 0, 59% for stage 1, 95% for stage 1 REM, 92% for stage 2, and 80% for stages 3+4. Values for standard sleep EEG-EOG parameters were generally similar among scoring laboratories, and interlaboratory scoring agreement compared favorably with one measure of intralaboratory agreement. The low agreement for stage 1 is attributable to the infrequent and sporadic occurrence of stage 1 and is considered to be trivial. That for stages 3+4 is more critical and is probably related to the subjective process involved in scoring these stages. These data indicated that these techniques produced a high degree of interlaboratory standardization, and consequently, concurrence in sleep stage scoring.

We have been attracted to studying the dream for two different but interrelated reasons. In the usual clinical tradition, we have been drawn to study the dream for the insights it may provide into the personality of the dreamer. From a more theoretical point of view, we have been interested in the psychology of dreaming, especially in searching for evidence of a possible function that dreaming serves. We have pursued a series of studies of dream reports of schizophrenic and depressed patients both for the contribution they could make to our understanding of the personality of the dreamer and to elucidate possible functions of the dream. In a study of the spontaneously recalled dream reports of depressed, schizophrenic, and medical patients, we were able to distinguish among them based on the systematic analysis of the content of their dream reports. 1 The content differences, such as the most frequent character in the depressed being a family member, in the schizophrenic a stranger, and in the medical patient a friend, did indeed provide potentially valuable insights into the personality of the dreamer. In our studies of collected dream reports (REM dreams from the laboratory) of schizophrenic 2 and depressed patients 3 before treatment and after significant improvement, we were able to show content differences which suggested that the collected dream report was reflective of the current emotional state of the patient. This supports the possibility that the dream may play some adaptational role in the psychic economy of the patient. The current report, which compares the content of REM-dream reports of depressed and schizophrenic patients, addresses itself both to the clinical problem, i.e., the light that dream reports may shed on the personality of depressed and schizophrenic patients, and to the psychology of dreaming, i.e., the possible functional significance of the dream.

An examination of the dreams of depressed patients revealed that there are measurable changes in dream content which accompany imipramine treatment and clinical improvement. The findings are consistent with a view of the intrapsychic condition in depression as being high in feelings of hostility and anxiety and low in heterosexuality and motility. The essential psychopharmacologic action of imipramine in depression is a two-step effect in which hostility is mobilized and then discharged.