Psychosomatics 2013:]:]]]–]]]
& 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Original Research Reports Insomnia in Patients With Unexplained Chest Pain Geneviève Belleville, Ph.D., Guillaume Foldes-Busque, Psy.D., Ph.D., Julien Poitras, M.D., Jean-Marc Chauny, M.D., M.Sc., Jean G. Diodati, M.D., Richard Fleet, M.D., Ph.D., André Marchand, Ph.D.
Objectives: The current study was designed (1) to assess insomnia symptoms and sleep-related beliefs in a population of patients presenting in emergency department with unexplained chest pain (UCP) and (2) to examine the associations between insomnia and pain. Methods: This is a report of secondary data from a cross-sectional study performed in the emergency department of 2 academic hospitals. Patients with UCP seen in an emergency department were assessed using sleep questionnaires and the Anxiety Disorders Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Results: Nearly every second patient with UCP (44%) seen in an emergency department suffered from clinically significant insomnia symptoms. Most patients with an anxiety or a mood disorder had insomnia, but a minority of patients with insomnia had an anxiety or a mood disorder. Insomniacs with an anxiety disorder were
similar to insomniacs without comorbid anxiety for sleep-related beliefs and depressive symptoms, and both groups of insomniacs reported more depressive symptoms and faulty beliefs than both groups of good sleepers, i.e., either with or without an anxiety disorder. Results from regression analyses revealed that insomnia was associated with pain on univariate regression analysis and accounted for 1.3% of the variance in both pain intensity and interference. However, this association was rendered nonsignificant when additional variables were added to the model. Conclusions: Insomnia symptoms are an important, but often disregarded, feature present in a significant proportion of patients with UCP. As insomnia showed stronger associations with pain than anxiety or depression, it may represent an important factor contributing to the development and recurrence of UCP. (Psychosomatics 2013; ]:]]]–]]])
C
disorder) report insomnia.5,6 Insomnia increases risk of depression and anxiety7; it is also a common residual
hest pain is the second most frequent reason for consultation in emergency departments (ED).1 In the United States, more than 5 million individuals are seen in an ED with a chief complaint of chest pain each year.2 Approximately 50% of these patients present with noncardiac or unexplained chest pain (UCP).3 Interestingly, a large proportion of patients with UCP (20%–40%) also have a psychiatric disorder4; anxiety and mood disorders, particularly panic disorder and major depressive disorder, are the most common. Anxiety and mood disorders are closely associated with sleep problems. Epidemiologic surveys have demonstrated that 70%–90% of individuals with an anxiety disorder or a mood disorder (often major depressive Psychosomatics ]:], ] 2013
Received October 25, 2013; revised December 2, 2013; accepted December 4, 2013. From School of Psychology, Université Laval, Québec, Canada (GB, G F-B); The University-Affiliated Hospital of Lévis, Québec, Canada (G F-B, JP, RF); Department of Family Medicine and Emergency Medicine, Université Laval, Québec, Canada (JP, RF) ; Sacré-Coeur Hospital Research Centre, Québec, Canada (J-M C, JGD); Department of Psychology, Université du Québec à Montréal, Montréal, Canada (AM); Intervention Axis, Centre de Recherche Fernand-Seguin, Mentréal, Canada (AM). Send correspondence and reprint requests to Genevieve Belleville, Ph.D., École de Psychologie, Université Laval, 2325, rue des Bibliotheques, Québec G1V 0A6, Canada; e-mail: genevieve. [email protected] & 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
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Insomnia in Patients With Chest Pain symptom after successful treatment for these problems8 and increases the risk of relapse.9 Therefore, UCP seems to be associated with some degree of sleep difficulties,10 although a thorough assessment of insomnia symptoms in this population has yet to be done. Significant data are available concerning the prevalence, detection, consequences, and costs of insomnia in patients in primary care clinics. Insomnia is present in 25%–35% of patients who consult a general practitioner.11,12 The prevalence rate increases to 59% in patients with anxiety or depression.12 It is noteworthy that 50%–69% of patients do not report their insomnia symptoms to their physician11; underreporting is attributed to general practice patients' perceived difficulty convincing physicians that their sleep difficulties are serious.13 The rate of detection of sleep problems may be even lower in patients with UCP than in general medicine patients because physicians' inquiry and validation of symptoms tends to be less thorough in patients in the former population.14 Inquiring about sleep problems by physicians is essential because insomnia is associated with poor health status, depression, and dysfunctional beliefs15 as well as decreased productivity and significant functional impairment.16 Individuals with insomnia report greater health care use,12,16 with longer and more frequent hospitalizations and emergency room visits.17 They also report more physical pain than do good sleepers.18 The direct and indirect costs of this problem are estimated to be approximately $15 billion per year, i.e., $2000 per patient with insomnia per year.19 Thus, insomnia symptoms may plausibly contribute to the overall socioeconomic burden of UCP. In summary, patients with UCP complain of unexplained somatic symptoms, leading them to visit an ED frequently, where they are administered numerous costly tests that often yield negative results. Although not yet empirically demonstrated, it is likely that this population suffers from significant insomnia, which may be associated with their pain. The objectives of the present study were (1) to assess insomnia symptoms in a population of patients presenting to an ED with UCP and (2) to examine the associations between insomnia and pain. Our main research questions were as follows: (1) what is the proportion of individuals with UCP who report significant insomnia, (2) are insomnia symptoms associated with an underlying anxiety or mood disorder in this population, and (3) is insomnia associated with pain intensity? 2
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METHOD This study represents secondary analyses from a crosssectional study of panic in ED patients with UCP.20 The research protocol was approved by the ethics committee at the Montreal Sacré-Coeur Hospital and the University-Affiliated Hospital of Levis, and participants gave written informed consent. Montreal Sacré-Coeur Hospital serves an urban population, and the University-Affiliated Hospital of Levis serves a rural and urban population. The 2 hospitals are roughly 250 km apart. Each ED receives approximately 50,000 visits per year. Data collection for the primary study had already started when sleep assessment was included in the protocol. As a consequence, only a proportion (n ¼ 324; 42%) of the original sample (n ¼ 771) is included in the present study. There were no significant differences on sociodemographic characteristics (age, gender, marital status, and employment status) between participants who provided sleep data and those who did not. Participants Participants were recruited from Monday to Friday between 8 AM and 4 PM (refer to Figure 1 for the recruitment flowchart). To be eligible for the study, patients had to be at least 18 years old, fluent in written and oral English or French, and report chest pain with a negative serial electrocardiogram and cardiac enzyme test results (troponin o 0.06). Exclusion criteria included any objective medical cause for chest pain (e.g., cause identifiable by radiography; positive stress test result; or objective signs of ischemia, arrhythmia, or myocardial necrosis), any medical condition that could invalidate the interview (e.g., psychotic state, intoxication, intellectual deficiency, or cognitive disorder), any unstable medical condition that could prevent the proceedings of the interview and questionnaire completion, and any documented trauma to or near the chest. Protocol Research assistants accessed ED databases to identify consecutive patients who presented with chest pain, and consulted patients' medical records to assess eligibility. The evaluation interview was administered Psychosomatics ]:], ] 2013
Belleville et al. to eligible patients who consented to participate while they were waiting in the ED for consultations or test results. Participants also completed questionnaires about symptoms of insomnia, anxiety, and depression. The research assistants were trained in the administration of the semistructured diagnostic interview and supervised by 2 licensed psychologists (G. B. and A. M.). The evaluation interviews were audio recorded, and 25% of interviews were randomly selected for review to measure inter-rater agreement on psychiatric diagnoses. Three medical archivists and 1 registered nurse abstracted the participants' medical files to obtain further details about the ED evaluation, including referrals for outpatient tests, medical history, medical treatment received in the ED, identification of panic, and tests results (including outpatient tests). The archivists and nurse used a standardized abstraction form and a detailed coding book. They were blind to the specific objectives of the study and to the participants' psychiatric status. Medical files were reviewed a minimum of 30 days after the participant was discharged. Ambiguous cases were discussed with one of the investigators (G. F. B.); discrepancies were presented to the research team physicians (J. G. D., J. M. C., J. P., and R. F.) and resolved by consensus. Two abstractors evaluated inter-rater agreement with data from 10% of randomly-selected participants.
reported. Chest pain intensity was measured with the corresponding item from the panic symptoms checklist included in the ADIS-IV panic disorder section. The ADIS-IV panic symptoms checklist was systematically administered to all participants (i.e., regardless of whether they reported panic attacks). Patients were asked to give a severity rating between 0 (“none”) and 8 (“very severe”) for each of the 13 panic symptoms, including chest pain or discomfort. Sociodemographic and medical interviews. This brief interview was used to gather sociodemographic data, family medical history, and information about type of chest pain. Interference caused by pain was measured by the question “In the past week, how much have you been disturbed by chest or heart pain?” Patients were asked to give a severity rating between 0 (“not at all”) and 4 (“extremely”). Self-Report Questionnaires Insomnia Severity Index. The Insomnia Severity Index (ISI) 23 assesses sleep impairment and daytime consequences with 7 Likert-type items. A cutoff score of 10 or more has been identified as the one that best discriminates insomniacs from good sleepers in the general population.24 The ISI has good internal consistency and is a reliable subjective measure for assessing sleep impairment. The French-language version has previously been validated.25
Measures Clinical Interviews and Pain Measures Anxiety Disorders Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (ADIS-IV). The ADIS-IV is a diagnostic interview recommended for the evaluation of anxiety disorders for research purposes.21 The ADIS-IV has good psychometric properties and particularly strong inter-rater reliability in patients with UCP.22 The following disorders were evaluated: panic disorder with or without agoraphobia, social phobia, specific phobia, obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, major depression, dysthymia, bipolar disorder, hypochondria, somatization disorder, substance abuse, and substance dependence. Owing to very low prevalence rates (n r 5), hypochondria, somatization disorder, and substance abuse and dependence were not Psychosomatics ]:], ] 2013
Dysfunctional Beliefs and Attitudes About Sleep Scale. The Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS)23,26 was developed to evaluate sleep-disruptive cognitions. The DBAS includes 30 items that are rated on a 10-point Likert scale. Items are divided into 5 subscales: (1) beliefs about sleep requirements, (2) beliefs about sleeppromoting practices, (3) beliefs about consequences of insomnia, (4) beliefs about control or predictability of sleep, and (5) beliefs about causes of insomnia (attributions). The DBAS has been found to be reliable for discriminating between self-defined good and poor sleepers in adults.27 The French-language version has previously been validated.25 Anxiety Sensitivity Index. Fear of anxiety-related symptoms was measured using the Anxiety Sensitivity Index (ASI).28 This 16-item instrument has a 5www.psychosomaticsjournal.org
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Insomnia in Patients With Chest Pain point scale that measures the tendency to attribute negative consequences to anxious symptoms. It presents good internal consistency, good temporal stability, and satisfactory test-retest reliability.28 This questionnaire was selected because it is considered to be able to detect panic disorder in patients undergoing nuclear testing for chest pain.29 The French-language version has previously been validated.30
and age), pain indicators (severity and interference), mood/anxiety disorders, and questionnaires scores (ISI, ASI, and BDI-II) were calculated. Only sex and age were significantly (p o 0.01) correlated with pain. Sex and age were thus included to the regression models (model 2). In accordance with our research questions, we also added the presence of anxiety and mood disorders as covariables in the model (model 3).
Beck Depression Inventory—Revised. Presence and severity of depressive symptoms were measured using the Beck Depression Inventory—revised (BDIII).31 This 21-item instrument evaluates the severity of symptoms on a 4-point scale and is based on the DSMIV criteria for major depressive disorder. The BDI-II is commonly used in research and has been extensively validated. The French-language version of the BDI-I has previously been validated,32 and the Frenchlanguage BDI-II has been revised in accordance with revisions to the English-language version.
RESULTS
Statistical Analyses Participants were grouped based on whether they had insomnia, an anxiety disorder, a mood disorder, or any combination of the 3 (Figure 2). People with insomnia (subsequently referred to as “insomniacs” for simplicity) were identified using the ISI cutoff score of 10.24 Anxiety and mood disorders were diagnosed with the ADIS-IV. Five participants had an anxiety disorder and a mood disorder, 5 had insomnia and a mood disorder, and 10 had insomnia with both an anxiety disorder and a mood disorder (no participant had a mood disorder without insomnia or anxiety or both). Owing to very small group number, these groups, accounting for 20 participants, were excluded from the comparison analyses. Clinical characteristics (insomnia severity, sleep-related beliefs, sensitivity to anxiety, depressive symptoms, and pain) were compared using analyses of variance. Significant omnibus F tests were followed by a posteriori Tukey tests. To assess the associations of insomnia and pain, 2 sets of hierarchical multiple regression analyses were performed, with chest pain intensity and interference caused by pain as separate outcome variables. We first assessed the univariate contribution of insomnia symptoms severity (model 1). To determine which variables to enter in the multivariate models, correlations coefficients between sociodemographic characteristics (sex 4
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Description of the Sample The final sample was composed of 324 participants (47% women) (Figure 1). Sociodemographic characteristics are presented in Table 1. Mean age was 54.60 years (standard deviation ¼ 15.04 y; range: 18–93 y). There was a significant difference between groups regarding age (F(3,299) ¼ 7.97; p o 0.001): participants with an anxiety disorder were younger than good sleepers. Most participants had completed high school (37%) or college (40%) education. Most participants (65%) were married or in a common-law relationship. There was a statistically significant difference between groups regarding marital status (χ2(3) ¼ 10.08; p ¼ 0.018), with a greater proportion of single participants among individuals with insomnia. Approximately one-half of the sample (57%) was employed. Insomnia Symptoms, Anxiety Disorders, and Mood Disorders According to the validated criterion for determining insomnia cases in community samples (ISI Z 10),24 144 participants (44%) could be considered as insomniacs (Figure 2). Most insomniacs (60% or 86/144) did not have a comorbid anxiety or mood disorder, a significant proportion (37% or 53/144) had a comorbid anxiety disorder, and a few had a comorbid mood disorder (5% or 15/144). It is interesting to note that, of all participants with an anxiety disorder (n ¼ 93), a majority also had insomnia (57% or 53/93). Associations Between Insomnia and Pain Questionnaires scores are presented in Table 2. There was a significant difference between groups on ISI total score (F(3,300) ¼ 272.23; p o 0.001). Psychosomatics ]:], ] 2013
Belleville et al. FIGURE 1.
Participant Flowchart. ED patients with chest pain (n = 7,136)
Patients unavailable (n = 2,386)
Excluded patients (n = 3,056) - Cause for chest pain found: 68.5% (n = 2,095)
Screened for eligibility (n = 4,750)
- Unable to complete interview = 17.9% (n = 525) - Not fluent in English or French = 7.8 % (n = 239) - Other = 6.4% (n = 197)
Non-consenting patients (n = 635) - Not interested = 41.6% (n = 264)
Eligible patients (n = 1,694) - Tired/not feeling well = 42.5 % (n = 270) - Other = 15.9% (n = 101)
Excluded after review of medical file (n = 288) - Cause for chest pain found = 81.9% (n = 244)
Consenting patients (n = 1,059)
- Medical record unavailable = 18.1% (n = 44)
Patients without sleep data (n = 447) Original study sample (n = 771)
- Recruited before amendment to include sleep evaluation = 73.4% (n = 328) - Incomplete sleep data = 26.6% (n = 119)
Patients with sleep data (n = 324)
Although it was predictable that both groups of insomniacs would have greater ISI scores than both groups of good sleepers (because of the use of the ISI cutoff score to form groups), it was interesting to note that insomniacs with an anxiety disorder showed more severe insomnia symptoms than insomniacs without an anxiety disorder. There was significant differences between groups on DBAS total score (F(3,297) ¼ 23.93; p o 0.001) and all DBAS subscale scores (sleep needs: F(3,295) ¼ 4.94, p ¼ 0.002; sleeppromoting practices: F(3,296) ¼ 12.28, p o 0.001; consequences of insomnia: F(3,296) ¼ 21.45, p o 0.001; and control or predictability of sleep: F(3,292) ¼ 26.35, p o 0.001), except for causal attributions of insomnia (F(3,289) ¼ 2.01; p ¼ 0.11). Except for causal attributions of insomnia and sleep needs, both groups of insomniacs endorsed stronger dysfunctional beliefs and attitudes about sleep than both groups of good sleepers. There was a significant difference between groups on ASI total score (F(3,289) ¼ 14.60; p o 0.001). Psychosomatics ]:], ] 2013
Insomniacs with an anxiety disorder had greater sensitivity to anxiety than insomniacs without an anxiety disorder who, in turn, had greater sensitivity to anxiety than good sleepers. There was a significant difference between groups on BDI-II total score (F (3,289) ¼ 24.57; p o 0.001). Again, both groups of insomniacs had greater scores than both groups of good sleepers. Differences between groups regarding chest pain intensity and interference caused by pain were not statistically different. Results from hierarchical multiple regression analyses indicated that, taken alone, insomnia symptoms severity accounted for 1.3% of chest pain intensity variance (F(1,308) ¼ 4.93; p ¼ 0.027) and for 1.3% of interference caused by chest pain (F(1,307) ¼ 5.08; p ¼ 0.025) (Table 3). The addition of sex and age in the model provided a significant increase in accounting for chest pain intensity variance (Finc(2,306) ¼ 8.92; p o 0.001) and interference caused by pain (Finc(2,305) ¼ 6.21; p ¼ 0.002). The 2 pain ratings were more severe www.psychosomaticsjournal.org
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Insomnia in Patients With Chest Pain TABLE 1.
Sociodemographic Characteristics Good sleepers Good sleepers þ AD Insomniacs (n ¼ 140) (n ¼ 35) (n ¼ 86)
Insomniacs þ AD Total sample (n ¼ 43) (n ¼ 324)*
Age (mean ⫾ SD)
58.57 ⫾ 13.67a 46.56 ⫾ 12.99b
54.05 ⫾ 17.12a,b 50.65 ⫾ 13.72b
54.60 ⫾ 15.04
Female gender (%)
41
49
43
58
47
Education High school degree (%) College degree (%)
37 39
31 54
36 40
42 33
37 40
Marital status† Married or in a common-law relationship (%) 71 Single (%) 29
74 26
52 48
67 33
65 36
Employment status Currently employed (%) Retired (%) Unemployed (%)
74 23 3
59 35 6
61 21 19
57 32 11
53 36 11
AD ¼ anxiety disorder; SD ¼ standard deviation. Note: Different letters indicate post hoc significant differences (Tukey tests), with p o 0.05. n
Five participants had an anxiety disorder and a mood disorder, 5 had insomnia and a mood disorder, and 10 had insomnia with both an anxiety disorder and a mood disorder (no participant had a mood disorder without insomnia or anxiety or both). Owing to very small group number, these groups, accounting for 20 participants, were excluded from the analyses. † 2 χ (3) ¼ 10.08, p ¼ 0.018.
among females and decreased with age. The inclusion of sex and age in the model decreased the association between insomnia severity and pain, rendering it statistically nonsignificant. The addition of anxiety
FIGURE 2.
and mood disorders in the model did not provide a significant increase in accounting for chest pain intensity variance (Finc(2,304) ¼ 0.29; p ¼ 0.75) or interference caused by chest pain (Finc(2,303) ¼ 1.32; p ¼ 0.266).
Number of Patients With Insomnia, Anxiety Disorders, and Mood Disorders in the Sample (n ¼ 324).
Anxiety Disorders (n=993) -Paanic Disorder (53) -A Agoraphobia (12) -Soocial Phobia (9) -G Generalized Anxietyy Disorder (34) Obsessive-Compulsiive Disorder (7) -O -Sppecific Phobia (29)) -Poost-Traumatic Stress Disorder (4)
43 5 10 5
Insomnia (n=144) Mood Disorrders (n=20) - Majoor Depression Disorrder (14) - Dysthhymia (7) - Bipollar Disorder (4)
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Belleville et al. TABLE 2.
Insomnia Symptoms and Dysfunctional Beliefs and Attitudes About Sleep in Insomniacs and Good Sleepers Good sleepers (n ¼ 180)
ISI total score DBAS total score DBAS subscales Sleep needs Sleep-promoting practices Consequences of insomnia Control/predictability of sleep Causal attributions ASI total score BDI-II total score Chest pain intensity (0–8) Interference caused by pain
4.47 (2.80)a 3.28 (1.40)a 4.57 3.65 3.16 2.60 3.11 13.74 6.50 5.10 1.60
(1.64)a (1.71)a (1.78)a (1.55)a (2.05)a (8.86)a (5.81)a (2.27)a (1.16)a
Good sleepers þ AD (n ¼ 35) 4.94 (2.72)a 3.38 (1.57)a 4.37 (1.76)a 3.49 (1.59)a 3.53 (2.10)a 2.81 (1.68)a 3.34 (2.62)a 16.84 (11.23)a,b 9.48 (7.05)a 5.68 (1.79)a 1.74 (1.22)a
Insomniacs (n ¼ 86)
Insomniacs þ AD (n ¼ 43)
14.16 (3.35)b 4.47 (1.27)b
16.92 (3.94)c 4.93 (1.33)a
5.23 (1.56)b 4.42 (1.45)b 4.74 (1.89)b 4.12 (1.59)b 3.79(2.53)b 17.99 (11.02)b 13.74 (8.50)b 5.72 (1.69)a 2.01 (1.10)a
5.29 5.16 5.21 4.59 3.84 25.52 14.91 5.81 1.81
(1.49)a,b (1.73)b (1.62)b (1.71)b (2.21)a (10.97)c (8.34)b (1.85)a (1.22)a
Total sample (n ¼ 324)* 9.20 (6.12) 3.89 (1.52) 4.86 (1.66) 4.07 (1.70) 3.98 (2.01) 3.40 (1.80) 3.46 (2.30) 17.80 (11.54) 11.08 (9.16) 5.45 (2.01) 1.78 (1.17)
AD ¼ anxiety disorder; ASI ¼ anxiety sensitivity index; BDI-II ¼ Beck Depression Inventory, second edition; DBAS ¼ dysfunctional beliefs and attitudes about sleep scale; ISI ¼ insomnia severity index. Note: Different letters indicate post hoc significant differences (Tukey tests), with p o 0.05. n Five participants had an anxiety disorder and a mood disorder, 5 had insomnia and a mood disorder, and 10 had insomnia with both an anxiety disorder and a mood disorder (no participant had a mood disorder without insomnia or anxiety or both). Owing to very small group number, these groups, accounting for 20 participants, were excluded from the analyses.
To ensure that these findings were not because of variability related to how the constructs were measured, the analyses were repeated with the ASI score for anxiety symptoms severity (instead of presence of an anxiety disorder) and the BDI-II score for depressive symptoms severity (instead of presence of a mood disorder). Results (not reported) were similar to those obtained with the diagnoses of anxiety and mood disorders; in the multivariate models, only sex and age were significantly associated with pain intensity and interference.
DISCUSSION This study was designed to assess insomnia symptoms in a population of patients presenting in ED with UCP and to examine the associations between insomnia and pain. Regarding the proportion of individuals with UCP who report significant insomnia, we observed that almost one-half of the 324 participants (44%) had important insomnia symptoms. Although Jerlock et al.10 had reported that 27% of ED patients with UCP had unspecified sleep problems, 8–14 times per month or more, this is the first study to report on specific insomnia symptoms in patients with UCP consulting an ED. In comparison, the prevalence of insomnia in patients consulting a general practitioner is 25%–59%.11,12 Most patients with an anxiety or a mood disorder had insomnia, but it is noteworthy that a minority of Psychosomatics ]:], ] 2013
patients with insomnia had an anxiety or mood disorder. The presence of insomnia symptoms was thus not necessarily associated with an underlying anxiety or mood disorder. Moreover, results from regression analyses suggested that insomnia symptoms severity was univariately associated with pain intensity and interference caused by pain. Although this is the first time that the role of insomnia in the perception of pain severity is studied in a sample of patients with UCP, insomnia and sleep quality have already been positively correlated with pain intensity in patients with chronic pain.33 One study of patients with chronic pain found that poorer sleep quality was a function of depressed mood rather than of pain intensity.34 This was not the case in our sample, where a diagnosis of mood disorder was not a significant predictor of pain. With a univariate regression that did not control for other factors, insomnia was significantly associated with pain and pain interference, but this association became nonsignificant when also including sociodemographic characteristics (sex and age) and the presence/ absence of a mood or anxiety disorder in the regression. Insomniacs with a comorbid anxiety disorder presented more severe insomnia symptoms and sensitivity to anxiety than insomniacs without an anxiety disorder. Mostly, however, insomniacs with an anxiety disorder were similar to insomniacs without comorbid anxiety in terms of sleep-related beliefs and depressive symptoms, and both groups of insomniacs reported www.psychosomaticsjournal.org
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Insomnia in Patients With Chest Pain TABLE 3.
Multiple Regression Analyses Predicting Chest Pain
Variables Intensity of chest pain (n ¼ 310) Model 1 Insomnia severity Model 2 Insomnia severity Sex (female) Age Model 3 Insomnia severity Sex (female) Age Presence of an anxiety disorder Presence of a mood disorder
B
(SE) B
0.019
0.125*
0.125
0.027 0.704 0.025
0.019 0.230 0.008
0.079 0.172* 0.182*
0.077 0.169 0.179
0.030 0.728 0.026 0.063 0.327
0.020 0.233 0.008 0.270 0.510
0.087 0.178* 0.187* 0.014 0.037
0.083 0.173 0.180 0.013 0.035
0.011
0.128*
0.128
0.011 0.132 0.004
0.090 0.131* 0.163*
0.088 0.129 0.161
0.011 0.134 0.005 0.154 0.291
0.102 0.136* 0.179* 0.095 0.050
0.097 0.133 0.173 0.087 0.047
Adjusted R2
ΔR2
0.013*
0.016*
0.061*
0.054*
0.056*
0.002
0.013*
0.016*
0.045*
0.038*
0.048*
0.008
p o 0.05.
more symptoms and faulty beliefs than both groups of good sleepers, i.e., either with or without an anxiety disorder. This is consistent with findings showing that the presence of simultaneous anxiety and insomnia creates a clinical portrait that is considerably more complex than that of anxiety in isolation. Individuals with a concurrent anxiety disorder and sleep disturbance have been demonstrated to have poorer mental health than do individuals with an anxiety disorder without sleep disturbances.6 Furthermore, absenteeism subsequent to emotional problems or substance use is 172%–189% more frequent in individuals who present both problems.6 The findings presented here have clinical relevance for professionals working in ED. In this clinical research study, important insomnia symptoms were reported in a significant proportion of patients presenting with UCP. Whether insomnia problems would turn out as common with systematic clinical assessment of insomnia in the ED is unknown. Although they can be associated with psychiatric comorbidities, such as anxiety and depression, insomnia symptoms may, more 8
sr2
0.043
Interference caused by chest pain (n ¼ 309) Model 1 Insomnia severity 0.025 Model 2 Insomnia severity 0.018 Sex (female) 0.306 Age 0.013 Model 3 Insomnia severity 0.020 Sex (female) 0.318 Age 0.014 Presence of an anxiety disorder 0.240 Presence of a mood disorder 0.249 n
β
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often than not, be present in the absence of any other psychiatric comorbidity. Unfortunately, owing to the cross-sectional nature of the data, it was not possible to determine whether insomnia symptoms were a precursor of anxiety or mood problems or both, a consequence of these, or an independent phenomenon. Given that pain and insomnia are associated, could sedative/hypnotic medication help patients with UCP to sleep better and report less pain? Although this question has never been studied in patients with UCP, available data in the literature suggest that the answer would not be straightforward. On the one hand, short-term use of hypnotic benzodiazepines, or nonbenzodiazepine molecules such as zopiclone or zolpidem, improves sleep and can decrease associated pain and anxiety.35,36 On the other hand, prolonged use of hypnotic medication is associated with undesirable effects, such as tolerance, rebound insomnia and anxiety, and daytime fatigue and difficulty concentrating.37,38 Furthermore, the gradual withdrawal of hypnotic medication after a prolonged use can have positive effects on sleep, anxiety, and physical health.39 Psychosomatics ]:], ] 2013
Belleville et al. Consensus guidelines indicate that the prescription of sedative/hypnotic medication should be restricted to short-term use, and that, in cases of chronic insomnia, nonpharmacologic approaches, namely cognitivebehavior therapy for insomnia, should be preferred.40 It is relevant to note that cognitive-behavior therapy for insomnia has positive effect on comorbid anxiety,41 depression,42 and pain.43 Successful treatment of insomnia can lead to decreased number of medical conditions and visits and increased health-related quality of life.44 Sleep disturbances can be relatively simple to assess. Detection of insomnia and other sleep problems can be done with easy-to-administer questionnaires, such as the ISI or the Pittsburgh Sleep Quality Index.45 Very brief forms of cognitive-behavior therapy for insomnia have been developed for use in primary care clinics.46 Empirical studies have yet to show whether cognitivebehavior therapy for insomnia could have an effect on chest pain in this specific population. The findings of this study should be interpreted in light of some methodologic limitations. Results were obtained from secondary analyses, and the assessment of sleep difficulties was included while data collection had already started for the mother study. Consequently, sleep data were only available for a limited proportion (42%) of the original sample.20 The main limitation of this study stems from the absence of a validated measure of chest pain. Further studies are needed to ensure that insomnia is still significantly associated with pain in patients with UCP when the latter is measured with a validated instrument. Despite these limitations, this study is the first to assess sleep disturbances in a sample of emergency patients with UCP, an understudied and difficult-to-track population. Insomnia symptoms and
sleep-related beliefs were measured with validated questionnaires, and the sample was relatively large. CONCLUSION Nearly half of emergency department patients with UCP suffered from important insomnia symptoms, a rate of sleep disturbances similar to that observed in general practices populations. The presence of insomnia was not necessarily a symptom of an underlying anxiety or mood disorder. Insomnia might be more linked to pain and pain interference than are mood and anxiety disorders: insomnia was associated with pain on univariate regression and accounted for 1.3% of the variance in both pain severity and interference. However, this association was rendered nonsignificant when additional variables were added to the model; furthermore, there were no significant differences on pain severity and interference between individuals with insomnia or anxiety disorders, or both, as groups. Although not life-threatening, sleep disturbances may be associated with the report of physical symptoms, such as pain, and lead to further emergency medical visits, reason enough for these conditions to be addressed in the ED. Geneviève Belleville received postdoctoral scholarships from the Research Group on agoraphobia and panic and the Fonds de Recherche en Santé du Québec. The research was funded by a grant to André Marchand from the Canadian Institutes of Health Research (153245). Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
References 1. Ly N, McCaig LF: National Hospital Ambulatory Medical Care Survey: 2000 outpatient department summary. Adv Data 2002; 4(327):1–27 2. Hutter AM Jr, Amsterdam EA, Jaffe AS: 31st Bethesda Conference. Emergency Cardiac Care. Task force 2: acute coronary syndromes: section 2B—chest discomfort evaluation in the hospital. J Am Coll Cardiol 2000; 35(4):853–862 [PubMed PMID: 10732881. Epub 2000/03/25. eng] 3. Kontos MC, Jesse RL: Evaluation of the emergency department chest pain patient. Am J Cardiol 2000; 85(5A):32B–39B [PubMed PMID: 11076129. Epub 2000/11/15. eng] 4. Wulsin LR, Arnold LM, Hillard JR: Axis I disorders in ER patients with atypical chest pain. Int J Psychiatry Med 1991; 21(1):37–46 [PubMed PMID: 2066256]
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42. Manber R, Edinger JD, Gress JL, San Pedro-Salcedo MG, Kuo TF, Kalista T: Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep 2008; 31(4):489–495 [PubMed PMID: 18457236] 43. Currie SR, Wilson KG, Pontefract AJ, deLaplante L: Cognitive-behavioral treatment of insomnia secondary to chronic pain. J Consult Clin Psychol 2000; 68(3):407–416 [PubMed PMID: 10883557] 44. Martin SA, Aikens JE, Chervin RD: Toward costeffectiveness analysis in the diagnosis and treatment of insomnia. Sleep Med Rev 2004; 8(1):63–72 [PubMed PMID: 15062211. Epub 2004/04/06. eng] 45. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ: The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res 1989; 28(2):193–213 [Epub 1989/05/01. eng] 46. Edinger JD, Sampson WS: A primary care “friendly” cognitive behavioral insomnia therapy. Sleep 2003; 26 (2):177–182 [PubMed PMID: 12683477]
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& 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Original Research Reports Insomnia in Patients With Unexplained Chest Pain Geneviève Belleville, Ph.D., Guillaume Foldes-Busque, Psy.D., Ph.D., Julien Poitras, M.D., Jean-Marc Chauny, M.D., M.Sc., Jean G. Diodati, M.D., Richard Fleet, M.D., Ph.D., André Marchand, Ph.D.
Objectives: The current study was designed (1) to assess insomnia symptoms and sleep-related beliefs in a population of patients presenting in emergency department with unexplained chest pain (UCP) and (2) to examine the associations between insomnia and pain. Methods: This is a report of secondary data from a cross-sectional study performed in the emergency department of 2 academic hospitals. Patients with UCP seen in an emergency department were assessed using sleep questionnaires and the Anxiety Disorders Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Results: Nearly every second patient with UCP (44%) seen in an emergency department suffered from clinically significant insomnia symptoms. Most patients with an anxiety or a mood disorder had insomnia, but a minority of patients with insomnia had an anxiety or a mood disorder. Insomniacs with an anxiety disorder were
similar to insomniacs without comorbid anxiety for sleep-related beliefs and depressive symptoms, and both groups of insomniacs reported more depressive symptoms and faulty beliefs than both groups of good sleepers, i.e., either with or without an anxiety disorder. Results from regression analyses revealed that insomnia was associated with pain on univariate regression analysis and accounted for 1.3% of the variance in both pain intensity and interference. However, this association was rendered nonsignificant when additional variables were added to the model. Conclusions: Insomnia symptoms are an important, but often disregarded, feature present in a significant proportion of patients with UCP. As insomnia showed stronger associations with pain than anxiety or depression, it may represent an important factor contributing to the development and recurrence of UCP. (Psychosomatics 2013; ]:]]]–]]])
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disorder) report insomnia.5,6 Insomnia increases risk of depression and anxiety7; it is also a common residual
hest pain is the second most frequent reason for consultation in emergency departments (ED).1 In the United States, more than 5 million individuals are seen in an ED with a chief complaint of chest pain each year.2 Approximately 50% of these patients present with noncardiac or unexplained chest pain (UCP).3 Interestingly, a large proportion of patients with UCP (20%–40%) also have a psychiatric disorder4; anxiety and mood disorders, particularly panic disorder and major depressive disorder, are the most common. Anxiety and mood disorders are closely associated with sleep problems. Epidemiologic surveys have demonstrated that 70%–90% of individuals with an anxiety disorder or a mood disorder (often major depressive Psychosomatics ]:], ] 2013
Received October 25, 2013; revised December 2, 2013; accepted December 4, 2013. From School of Psychology, Université Laval, Québec, Canada (GB, G F-B); The University-Affiliated Hospital of Lévis, Québec, Canada (G F-B, JP, RF); Department of Family Medicine and Emergency Medicine, Université Laval, Québec, Canada (JP, RF) ; Sacré-Coeur Hospital Research Centre, Québec, Canada (J-M C, JGD); Department of Psychology, Université du Québec à Montréal, Montréal, Canada (AM); Intervention Axis, Centre de Recherche Fernand-Seguin, Mentréal, Canada (AM). Send correspondence and reprint requests to Genevieve Belleville, Ph.D., École de Psychologie, Université Laval, 2325, rue des Bibliotheques, Québec G1V 0A6, Canada; e-mail: genevieve. [email protected] & 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
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Insomnia in Patients With Chest Pain symptom after successful treatment for these problems8 and increases the risk of relapse.9 Therefore, UCP seems to be associated with some degree of sleep difficulties,10 although a thorough assessment of insomnia symptoms in this population has yet to be done. Significant data are available concerning the prevalence, detection, consequences, and costs of insomnia in patients in primary care clinics. Insomnia is present in 25%–35% of patients who consult a general practitioner.11,12 The prevalence rate increases to 59% in patients with anxiety or depression.12 It is noteworthy that 50%–69% of patients do not report their insomnia symptoms to their physician11; underreporting is attributed to general practice patients' perceived difficulty convincing physicians that their sleep difficulties are serious.13 The rate of detection of sleep problems may be even lower in patients with UCP than in general medicine patients because physicians' inquiry and validation of symptoms tends to be less thorough in patients in the former population.14 Inquiring about sleep problems by physicians is essential because insomnia is associated with poor health status, depression, and dysfunctional beliefs15 as well as decreased productivity and significant functional impairment.16 Individuals with insomnia report greater health care use,12,16 with longer and more frequent hospitalizations and emergency room visits.17 They also report more physical pain than do good sleepers.18 The direct and indirect costs of this problem are estimated to be approximately $15 billion per year, i.e., $2000 per patient with insomnia per year.19 Thus, insomnia symptoms may plausibly contribute to the overall socioeconomic burden of UCP. In summary, patients with UCP complain of unexplained somatic symptoms, leading them to visit an ED frequently, where they are administered numerous costly tests that often yield negative results. Although not yet empirically demonstrated, it is likely that this population suffers from significant insomnia, which may be associated with their pain. The objectives of the present study were (1) to assess insomnia symptoms in a population of patients presenting to an ED with UCP and (2) to examine the associations between insomnia and pain. Our main research questions were as follows: (1) what is the proportion of individuals with UCP who report significant insomnia, (2) are insomnia symptoms associated with an underlying anxiety or mood disorder in this population, and (3) is insomnia associated with pain intensity? 2
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METHOD This study represents secondary analyses from a crosssectional study of panic in ED patients with UCP.20 The research protocol was approved by the ethics committee at the Montreal Sacré-Coeur Hospital and the University-Affiliated Hospital of Levis, and participants gave written informed consent. Montreal Sacré-Coeur Hospital serves an urban population, and the University-Affiliated Hospital of Levis serves a rural and urban population. The 2 hospitals are roughly 250 km apart. Each ED receives approximately 50,000 visits per year. Data collection for the primary study had already started when sleep assessment was included in the protocol. As a consequence, only a proportion (n ¼ 324; 42%) of the original sample (n ¼ 771) is included in the present study. There were no significant differences on sociodemographic characteristics (age, gender, marital status, and employment status) between participants who provided sleep data and those who did not. Participants Participants were recruited from Monday to Friday between 8 AM and 4 PM (refer to Figure 1 for the recruitment flowchart). To be eligible for the study, patients had to be at least 18 years old, fluent in written and oral English or French, and report chest pain with a negative serial electrocardiogram and cardiac enzyme test results (troponin o 0.06). Exclusion criteria included any objective medical cause for chest pain (e.g., cause identifiable by radiography; positive stress test result; or objective signs of ischemia, arrhythmia, or myocardial necrosis), any medical condition that could invalidate the interview (e.g., psychotic state, intoxication, intellectual deficiency, or cognitive disorder), any unstable medical condition that could prevent the proceedings of the interview and questionnaire completion, and any documented trauma to or near the chest. Protocol Research assistants accessed ED databases to identify consecutive patients who presented with chest pain, and consulted patients' medical records to assess eligibility. The evaluation interview was administered Psychosomatics ]:], ] 2013
Belleville et al. to eligible patients who consented to participate while they were waiting in the ED for consultations or test results. Participants also completed questionnaires about symptoms of insomnia, anxiety, and depression. The research assistants were trained in the administration of the semistructured diagnostic interview and supervised by 2 licensed psychologists (G. B. and A. M.). The evaluation interviews were audio recorded, and 25% of interviews were randomly selected for review to measure inter-rater agreement on psychiatric diagnoses. Three medical archivists and 1 registered nurse abstracted the participants' medical files to obtain further details about the ED evaluation, including referrals for outpatient tests, medical history, medical treatment received in the ED, identification of panic, and tests results (including outpatient tests). The archivists and nurse used a standardized abstraction form and a detailed coding book. They were blind to the specific objectives of the study and to the participants' psychiatric status. Medical files were reviewed a minimum of 30 days after the participant was discharged. Ambiguous cases were discussed with one of the investigators (G. F. B.); discrepancies were presented to the research team physicians (J. G. D., J. M. C., J. P., and R. F.) and resolved by consensus. Two abstractors evaluated inter-rater agreement with data from 10% of randomly-selected participants.
reported. Chest pain intensity was measured with the corresponding item from the panic symptoms checklist included in the ADIS-IV panic disorder section. The ADIS-IV panic symptoms checklist was systematically administered to all participants (i.e., regardless of whether they reported panic attacks). Patients were asked to give a severity rating between 0 (“none”) and 8 (“very severe”) for each of the 13 panic symptoms, including chest pain or discomfort. Sociodemographic and medical interviews. This brief interview was used to gather sociodemographic data, family medical history, and information about type of chest pain. Interference caused by pain was measured by the question “In the past week, how much have you been disturbed by chest or heart pain?” Patients were asked to give a severity rating between 0 (“not at all”) and 4 (“extremely”). Self-Report Questionnaires Insomnia Severity Index. The Insomnia Severity Index (ISI) 23 assesses sleep impairment and daytime consequences with 7 Likert-type items. A cutoff score of 10 or more has been identified as the one that best discriminates insomniacs from good sleepers in the general population.24 The ISI has good internal consistency and is a reliable subjective measure for assessing sleep impairment. The French-language version has previously been validated.25
Measures Clinical Interviews and Pain Measures Anxiety Disorders Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (ADIS-IV). The ADIS-IV is a diagnostic interview recommended for the evaluation of anxiety disorders for research purposes.21 The ADIS-IV has good psychometric properties and particularly strong inter-rater reliability in patients with UCP.22 The following disorders were evaluated: panic disorder with or without agoraphobia, social phobia, specific phobia, obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, major depression, dysthymia, bipolar disorder, hypochondria, somatization disorder, substance abuse, and substance dependence. Owing to very low prevalence rates (n r 5), hypochondria, somatization disorder, and substance abuse and dependence were not Psychosomatics ]:], ] 2013
Dysfunctional Beliefs and Attitudes About Sleep Scale. The Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS)23,26 was developed to evaluate sleep-disruptive cognitions. The DBAS includes 30 items that are rated on a 10-point Likert scale. Items are divided into 5 subscales: (1) beliefs about sleep requirements, (2) beliefs about sleeppromoting practices, (3) beliefs about consequences of insomnia, (4) beliefs about control or predictability of sleep, and (5) beliefs about causes of insomnia (attributions). The DBAS has been found to be reliable for discriminating between self-defined good and poor sleepers in adults.27 The French-language version has previously been validated.25 Anxiety Sensitivity Index. Fear of anxiety-related symptoms was measured using the Anxiety Sensitivity Index (ASI).28 This 16-item instrument has a 5www.psychosomaticsjournal.org
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Insomnia in Patients With Chest Pain point scale that measures the tendency to attribute negative consequences to anxious symptoms. It presents good internal consistency, good temporal stability, and satisfactory test-retest reliability.28 This questionnaire was selected because it is considered to be able to detect panic disorder in patients undergoing nuclear testing for chest pain.29 The French-language version has previously been validated.30
and age), pain indicators (severity and interference), mood/anxiety disorders, and questionnaires scores (ISI, ASI, and BDI-II) were calculated. Only sex and age were significantly (p o 0.01) correlated with pain. Sex and age were thus included to the regression models (model 2). In accordance with our research questions, we also added the presence of anxiety and mood disorders as covariables in the model (model 3).
Beck Depression Inventory—Revised. Presence and severity of depressive symptoms were measured using the Beck Depression Inventory—revised (BDIII).31 This 21-item instrument evaluates the severity of symptoms on a 4-point scale and is based on the DSMIV criteria for major depressive disorder. The BDI-II is commonly used in research and has been extensively validated. The French-language version of the BDI-I has previously been validated,32 and the Frenchlanguage BDI-II has been revised in accordance with revisions to the English-language version.
RESULTS
Statistical Analyses Participants were grouped based on whether they had insomnia, an anxiety disorder, a mood disorder, or any combination of the 3 (Figure 2). People with insomnia (subsequently referred to as “insomniacs” for simplicity) were identified using the ISI cutoff score of 10.24 Anxiety and mood disorders were diagnosed with the ADIS-IV. Five participants had an anxiety disorder and a mood disorder, 5 had insomnia and a mood disorder, and 10 had insomnia with both an anxiety disorder and a mood disorder (no participant had a mood disorder without insomnia or anxiety or both). Owing to very small group number, these groups, accounting for 20 participants, were excluded from the comparison analyses. Clinical characteristics (insomnia severity, sleep-related beliefs, sensitivity to anxiety, depressive symptoms, and pain) were compared using analyses of variance. Significant omnibus F tests were followed by a posteriori Tukey tests. To assess the associations of insomnia and pain, 2 sets of hierarchical multiple regression analyses were performed, with chest pain intensity and interference caused by pain as separate outcome variables. We first assessed the univariate contribution of insomnia symptoms severity (model 1). To determine which variables to enter in the multivariate models, correlations coefficients between sociodemographic characteristics (sex 4
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Description of the Sample The final sample was composed of 324 participants (47% women) (Figure 1). Sociodemographic characteristics are presented in Table 1. Mean age was 54.60 years (standard deviation ¼ 15.04 y; range: 18–93 y). There was a significant difference between groups regarding age (F(3,299) ¼ 7.97; p o 0.001): participants with an anxiety disorder were younger than good sleepers. Most participants had completed high school (37%) or college (40%) education. Most participants (65%) were married or in a common-law relationship. There was a statistically significant difference between groups regarding marital status (χ2(3) ¼ 10.08; p ¼ 0.018), with a greater proportion of single participants among individuals with insomnia. Approximately one-half of the sample (57%) was employed. Insomnia Symptoms, Anxiety Disorders, and Mood Disorders According to the validated criterion for determining insomnia cases in community samples (ISI Z 10),24 144 participants (44%) could be considered as insomniacs (Figure 2). Most insomniacs (60% or 86/144) did not have a comorbid anxiety or mood disorder, a significant proportion (37% or 53/144) had a comorbid anxiety disorder, and a few had a comorbid mood disorder (5% or 15/144). It is interesting to note that, of all participants with an anxiety disorder (n ¼ 93), a majority also had insomnia (57% or 53/93). Associations Between Insomnia and Pain Questionnaires scores are presented in Table 2. There was a significant difference between groups on ISI total score (F(3,300) ¼ 272.23; p o 0.001). Psychosomatics ]:], ] 2013
Belleville et al. FIGURE 1.
Participant Flowchart. ED patients with chest pain (n = 7,136)
Patients unavailable (n = 2,386)
Excluded patients (n = 3,056) - Cause for chest pain found: 68.5% (n = 2,095)
Screened for eligibility (n = 4,750)
- Unable to complete interview = 17.9% (n = 525) - Not fluent in English or French = 7.8 % (n = 239) - Other = 6.4% (n = 197)
Non-consenting patients (n = 635) - Not interested = 41.6% (n = 264)
Eligible patients (n = 1,694) - Tired/not feeling well = 42.5 % (n = 270) - Other = 15.9% (n = 101)
Excluded after review of medical file (n = 288) - Cause for chest pain found = 81.9% (n = 244)
Consenting patients (n = 1,059)
- Medical record unavailable = 18.1% (n = 44)
Patients without sleep data (n = 447) Original study sample (n = 771)
- Recruited before amendment to include sleep evaluation = 73.4% (n = 328) - Incomplete sleep data = 26.6% (n = 119)
Patients with sleep data (n = 324)
Although it was predictable that both groups of insomniacs would have greater ISI scores than both groups of good sleepers (because of the use of the ISI cutoff score to form groups), it was interesting to note that insomniacs with an anxiety disorder showed more severe insomnia symptoms than insomniacs without an anxiety disorder. There was significant differences between groups on DBAS total score (F(3,297) ¼ 23.93; p o 0.001) and all DBAS subscale scores (sleep needs: F(3,295) ¼ 4.94, p ¼ 0.002; sleeppromoting practices: F(3,296) ¼ 12.28, p o 0.001; consequences of insomnia: F(3,296) ¼ 21.45, p o 0.001; and control or predictability of sleep: F(3,292) ¼ 26.35, p o 0.001), except for causal attributions of insomnia (F(3,289) ¼ 2.01; p ¼ 0.11). Except for causal attributions of insomnia and sleep needs, both groups of insomniacs endorsed stronger dysfunctional beliefs and attitudes about sleep than both groups of good sleepers. There was a significant difference between groups on ASI total score (F(3,289) ¼ 14.60; p o 0.001). Psychosomatics ]:], ] 2013
Insomniacs with an anxiety disorder had greater sensitivity to anxiety than insomniacs without an anxiety disorder who, in turn, had greater sensitivity to anxiety than good sleepers. There was a significant difference between groups on BDI-II total score (F (3,289) ¼ 24.57; p o 0.001). Again, both groups of insomniacs had greater scores than both groups of good sleepers. Differences between groups regarding chest pain intensity and interference caused by pain were not statistically different. Results from hierarchical multiple regression analyses indicated that, taken alone, insomnia symptoms severity accounted for 1.3% of chest pain intensity variance (F(1,308) ¼ 4.93; p ¼ 0.027) and for 1.3% of interference caused by chest pain (F(1,307) ¼ 5.08; p ¼ 0.025) (Table 3). The addition of sex and age in the model provided a significant increase in accounting for chest pain intensity variance (Finc(2,306) ¼ 8.92; p o 0.001) and interference caused by pain (Finc(2,305) ¼ 6.21; p ¼ 0.002). The 2 pain ratings were more severe www.psychosomaticsjournal.org
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Insomnia in Patients With Chest Pain TABLE 1.
Sociodemographic Characteristics Good sleepers Good sleepers þ AD Insomniacs (n ¼ 140) (n ¼ 35) (n ¼ 86)
Insomniacs þ AD Total sample (n ¼ 43) (n ¼ 324)*
Age (mean ⫾ SD)
58.57 ⫾ 13.67a 46.56 ⫾ 12.99b
54.05 ⫾ 17.12a,b 50.65 ⫾ 13.72b
54.60 ⫾ 15.04
Female gender (%)
41
49
43
58
47
Education High school degree (%) College degree (%)
37 39
31 54
36 40
42 33
37 40
Marital status† Married or in a common-law relationship (%) 71 Single (%) 29
74 26
52 48
67 33
65 36
Employment status Currently employed (%) Retired (%) Unemployed (%)
74 23 3
59 35 6
61 21 19
57 32 11
53 36 11
AD ¼ anxiety disorder; SD ¼ standard deviation. Note: Different letters indicate post hoc significant differences (Tukey tests), with p o 0.05. n
Five participants had an anxiety disorder and a mood disorder, 5 had insomnia and a mood disorder, and 10 had insomnia with both an anxiety disorder and a mood disorder (no participant had a mood disorder without insomnia or anxiety or both). Owing to very small group number, these groups, accounting for 20 participants, were excluded from the analyses. † 2 χ (3) ¼ 10.08, p ¼ 0.018.
among females and decreased with age. The inclusion of sex and age in the model decreased the association between insomnia severity and pain, rendering it statistically nonsignificant. The addition of anxiety
FIGURE 2.
and mood disorders in the model did not provide a significant increase in accounting for chest pain intensity variance (Finc(2,304) ¼ 0.29; p ¼ 0.75) or interference caused by chest pain (Finc(2,303) ¼ 1.32; p ¼ 0.266).
Number of Patients With Insomnia, Anxiety Disorders, and Mood Disorders in the Sample (n ¼ 324).
Anxiety Disorders (n=993) -Paanic Disorder (53) -A Agoraphobia (12) -Soocial Phobia (9) -G Generalized Anxietyy Disorder (34) Obsessive-Compulsiive Disorder (7) -O -Sppecific Phobia (29)) -Poost-Traumatic Stress Disorder (4)
43 5 10 5
Insomnia (n=144) Mood Disorrders (n=20) - Majoor Depression Disorrder (14) - Dysthhymia (7) - Bipollar Disorder (4)
6
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Psychosomatics ]:], ] 2013
Belleville et al. TABLE 2.
Insomnia Symptoms and Dysfunctional Beliefs and Attitudes About Sleep in Insomniacs and Good Sleepers Good sleepers (n ¼ 180)
ISI total score DBAS total score DBAS subscales Sleep needs Sleep-promoting practices Consequences of insomnia Control/predictability of sleep Causal attributions ASI total score BDI-II total score Chest pain intensity (0–8) Interference caused by pain
4.47 (2.80)a 3.28 (1.40)a 4.57 3.65 3.16 2.60 3.11 13.74 6.50 5.10 1.60
(1.64)a (1.71)a (1.78)a (1.55)a (2.05)a (8.86)a (5.81)a (2.27)a (1.16)a
Good sleepers þ AD (n ¼ 35) 4.94 (2.72)a 3.38 (1.57)a 4.37 (1.76)a 3.49 (1.59)a 3.53 (2.10)a 2.81 (1.68)a 3.34 (2.62)a 16.84 (11.23)a,b 9.48 (7.05)a 5.68 (1.79)a 1.74 (1.22)a
Insomniacs (n ¼ 86)
Insomniacs þ AD (n ¼ 43)
14.16 (3.35)b 4.47 (1.27)b
16.92 (3.94)c 4.93 (1.33)a
5.23 (1.56)b 4.42 (1.45)b 4.74 (1.89)b 4.12 (1.59)b 3.79(2.53)b 17.99 (11.02)b 13.74 (8.50)b 5.72 (1.69)a 2.01 (1.10)a
5.29 5.16 5.21 4.59 3.84 25.52 14.91 5.81 1.81
(1.49)a,b (1.73)b (1.62)b (1.71)b (2.21)a (10.97)c (8.34)b (1.85)a (1.22)a
Total sample (n ¼ 324)* 9.20 (6.12) 3.89 (1.52) 4.86 (1.66) 4.07 (1.70) 3.98 (2.01) 3.40 (1.80) 3.46 (2.30) 17.80 (11.54) 11.08 (9.16) 5.45 (2.01) 1.78 (1.17)
AD ¼ anxiety disorder; ASI ¼ anxiety sensitivity index; BDI-II ¼ Beck Depression Inventory, second edition; DBAS ¼ dysfunctional beliefs and attitudes about sleep scale; ISI ¼ insomnia severity index. Note: Different letters indicate post hoc significant differences (Tukey tests), with p o 0.05. n Five participants had an anxiety disorder and a mood disorder, 5 had insomnia and a mood disorder, and 10 had insomnia with both an anxiety disorder and a mood disorder (no participant had a mood disorder without insomnia or anxiety or both). Owing to very small group number, these groups, accounting for 20 participants, were excluded from the analyses.
To ensure that these findings were not because of variability related to how the constructs were measured, the analyses were repeated with the ASI score for anxiety symptoms severity (instead of presence of an anxiety disorder) and the BDI-II score for depressive symptoms severity (instead of presence of a mood disorder). Results (not reported) were similar to those obtained with the diagnoses of anxiety and mood disorders; in the multivariate models, only sex and age were significantly associated with pain intensity and interference.
DISCUSSION This study was designed to assess insomnia symptoms in a population of patients presenting in ED with UCP and to examine the associations between insomnia and pain. Regarding the proportion of individuals with UCP who report significant insomnia, we observed that almost one-half of the 324 participants (44%) had important insomnia symptoms. Although Jerlock et al.10 had reported that 27% of ED patients with UCP had unspecified sleep problems, 8–14 times per month or more, this is the first study to report on specific insomnia symptoms in patients with UCP consulting an ED. In comparison, the prevalence of insomnia in patients consulting a general practitioner is 25%–59%.11,12 Most patients with an anxiety or a mood disorder had insomnia, but it is noteworthy that a minority of Psychosomatics ]:], ] 2013
patients with insomnia had an anxiety or mood disorder. The presence of insomnia symptoms was thus not necessarily associated with an underlying anxiety or mood disorder. Moreover, results from regression analyses suggested that insomnia symptoms severity was univariately associated with pain intensity and interference caused by pain. Although this is the first time that the role of insomnia in the perception of pain severity is studied in a sample of patients with UCP, insomnia and sleep quality have already been positively correlated with pain intensity in patients with chronic pain.33 One study of patients with chronic pain found that poorer sleep quality was a function of depressed mood rather than of pain intensity.34 This was not the case in our sample, where a diagnosis of mood disorder was not a significant predictor of pain. With a univariate regression that did not control for other factors, insomnia was significantly associated with pain and pain interference, but this association became nonsignificant when also including sociodemographic characteristics (sex and age) and the presence/ absence of a mood or anxiety disorder in the regression. Insomniacs with a comorbid anxiety disorder presented more severe insomnia symptoms and sensitivity to anxiety than insomniacs without an anxiety disorder. Mostly, however, insomniacs with an anxiety disorder were similar to insomniacs without comorbid anxiety in terms of sleep-related beliefs and depressive symptoms, and both groups of insomniacs reported www.psychosomaticsjournal.org
7
Insomnia in Patients With Chest Pain TABLE 3.
Multiple Regression Analyses Predicting Chest Pain
Variables Intensity of chest pain (n ¼ 310) Model 1 Insomnia severity Model 2 Insomnia severity Sex (female) Age Model 3 Insomnia severity Sex (female) Age Presence of an anxiety disorder Presence of a mood disorder
B
(SE) B
0.019
0.125*
0.125
0.027 0.704 0.025
0.019 0.230 0.008
0.079 0.172* 0.182*
0.077 0.169 0.179
0.030 0.728 0.026 0.063 0.327
0.020 0.233 0.008 0.270 0.510
0.087 0.178* 0.187* 0.014 0.037
0.083 0.173 0.180 0.013 0.035
0.011
0.128*
0.128
0.011 0.132 0.004
0.090 0.131* 0.163*
0.088 0.129 0.161
0.011 0.134 0.005 0.154 0.291
0.102 0.136* 0.179* 0.095 0.050
0.097 0.133 0.173 0.087 0.047
Adjusted R2
ΔR2
0.013*
0.016*
0.061*
0.054*
0.056*
0.002
0.013*
0.016*
0.045*
0.038*
0.048*
0.008
p o 0.05.
more symptoms and faulty beliefs than both groups of good sleepers, i.e., either with or without an anxiety disorder. This is consistent with findings showing that the presence of simultaneous anxiety and insomnia creates a clinical portrait that is considerably more complex than that of anxiety in isolation. Individuals with a concurrent anxiety disorder and sleep disturbance have been demonstrated to have poorer mental health than do individuals with an anxiety disorder without sleep disturbances.6 Furthermore, absenteeism subsequent to emotional problems or substance use is 172%–189% more frequent in individuals who present both problems.6 The findings presented here have clinical relevance for professionals working in ED. In this clinical research study, important insomnia symptoms were reported in a significant proportion of patients presenting with UCP. Whether insomnia problems would turn out as common with systematic clinical assessment of insomnia in the ED is unknown. Although they can be associated with psychiatric comorbidities, such as anxiety and depression, insomnia symptoms may, more 8
sr2
0.043
Interference caused by chest pain (n ¼ 309) Model 1 Insomnia severity 0.025 Model 2 Insomnia severity 0.018 Sex (female) 0.306 Age 0.013 Model 3 Insomnia severity 0.020 Sex (female) 0.318 Age 0.014 Presence of an anxiety disorder 0.240 Presence of a mood disorder 0.249 n
β
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often than not, be present in the absence of any other psychiatric comorbidity. Unfortunately, owing to the cross-sectional nature of the data, it was not possible to determine whether insomnia symptoms were a precursor of anxiety or mood problems or both, a consequence of these, or an independent phenomenon. Given that pain and insomnia are associated, could sedative/hypnotic medication help patients with UCP to sleep better and report less pain? Although this question has never been studied in patients with UCP, available data in the literature suggest that the answer would not be straightforward. On the one hand, short-term use of hypnotic benzodiazepines, or nonbenzodiazepine molecules such as zopiclone or zolpidem, improves sleep and can decrease associated pain and anxiety.35,36 On the other hand, prolonged use of hypnotic medication is associated with undesirable effects, such as tolerance, rebound insomnia and anxiety, and daytime fatigue and difficulty concentrating.37,38 Furthermore, the gradual withdrawal of hypnotic medication after a prolonged use can have positive effects on sleep, anxiety, and physical health.39 Psychosomatics ]:], ] 2013
Belleville et al. Consensus guidelines indicate that the prescription of sedative/hypnotic medication should be restricted to short-term use, and that, in cases of chronic insomnia, nonpharmacologic approaches, namely cognitivebehavior therapy for insomnia, should be preferred.40 It is relevant to note that cognitive-behavior therapy for insomnia has positive effect on comorbid anxiety,41 depression,42 and pain.43 Successful treatment of insomnia can lead to decreased number of medical conditions and visits and increased health-related quality of life.44 Sleep disturbances can be relatively simple to assess. Detection of insomnia and other sleep problems can be done with easy-to-administer questionnaires, such as the ISI or the Pittsburgh Sleep Quality Index.45 Very brief forms of cognitive-behavior therapy for insomnia have been developed for use in primary care clinics.46 Empirical studies have yet to show whether cognitivebehavior therapy for insomnia could have an effect on chest pain in this specific population. The findings of this study should be interpreted in light of some methodologic limitations. Results were obtained from secondary analyses, and the assessment of sleep difficulties was included while data collection had already started for the mother study. Consequently, sleep data were only available for a limited proportion (42%) of the original sample.20 The main limitation of this study stems from the absence of a validated measure of chest pain. Further studies are needed to ensure that insomnia is still significantly associated with pain in patients with UCP when the latter is measured with a validated instrument. Despite these limitations, this study is the first to assess sleep disturbances in a sample of emergency patients with UCP, an understudied and difficult-to-track population. Insomnia symptoms and
sleep-related beliefs were measured with validated questionnaires, and the sample was relatively large. CONCLUSION Nearly half of emergency department patients with UCP suffered from important insomnia symptoms, a rate of sleep disturbances similar to that observed in general practices populations. The presence of insomnia was not necessarily a symptom of an underlying anxiety or mood disorder. Insomnia might be more linked to pain and pain interference than are mood and anxiety disorders: insomnia was associated with pain on univariate regression and accounted for 1.3% of the variance in both pain severity and interference. However, this association was rendered nonsignificant when additional variables were added to the model; furthermore, there were no significant differences on pain severity and interference between individuals with insomnia or anxiety disorders, or both, as groups. Although not life-threatening, sleep disturbances may be associated with the report of physical symptoms, such as pain, and lead to further emergency medical visits, reason enough for these conditions to be addressed in the ED. Geneviève Belleville received postdoctoral scholarships from the Research Group on agoraphobia and panic and the Fonds de Recherche en Santé du Québec. The research was funded by a grant to André Marchand from the Canadian Institutes of Health Research (153245). Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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