Sei sulla pagina 1di 7

,

~. Sleep, 19(9):691-697
© 1996 American Sleep Disorders Association and Sleep Research Society

Disrupted Nocturnal Sleep-Insomnia and Hypnotics


.,
First-Night-Effects on Generalized Anxiety
Disorder (GAD)-Based Insomnia:
Laboratory Versus Home Sleep Recordings
r'

Bernd Saletu, Gerhard KlOsch, Georg Gruber, Peter Anderer,


*Pichet Udomratn and Richard Frey

Department of Psychiatry, School of Medicine, University of Vienna, Austria; and


*Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Thailand

Summary: First-night effects (FNE) were comparatively investigated in patients with disorders in initiating and
maintaining sleep (DIMS) associated with generalized anxiety disorder (GAD) in laboratory (n = 22) and home
sleep polysomnography (n = 21). Patients had to be drug-free for at least 2 weeks prior to the first recording.
Evaluation measures included 1) objective data on sleep initiation and maintenance; 2) sleep architecture based on
polysomnographic recordings, analyzed visually according to the criteria of Rechtschaffen and Kales; 3) subjectively
estimated sleep and awakening quality, assessed by a self-rating scale and visual analogue scales; 4) objective
awakening quality as measured by a psychometric test battery; and 5) psychophysiological data, including critical
flicker frequency, muscle strength, pulse, and blood pressure. Statistical analysis using multivariate analysis of
variance (MANOVA) demonstrated mUltiple FNE in both groups regarding sleep efficiency, total sleep time, per-
centage of time in stage 2 sleep, percentage of time in stage 3/4 sleep, minutes of rapid eye movement (REM)
sleep, and REM sleep latency. There was a group-by-night effect in the number of awakenings. There were no
significant FNE regarding subjective sleep and awakening quality in either group. Differential adaptation effects
were observed in attention and fine motor activity, with improvement in laboratory-recorded patients and deterio-
ration in home-recorded patients. Differential findings also occurred in regard to evening blood pressure, with
laboratory-recorded patients showing more adaptation. Key Words: First-night effects-Insomnia-Generalized
anxiety disorder-Sleep laboratory recording-Ambulatory polysomnography-Objective sleep quality-Subjective
sleep quality-Awakening quality-Psychometry.

First-night effects (FNE) are a well-reported phe- Most of the information on FNE originates from
nomenon in sleep research. They are considered to re- studies conducted in the artificial surroundings of the
sult from a subject's lack of adaptation to the unfa- sleep laboratory. With the development of ambulatory
miliar environment of the sleep laboratory and to the PSG, it became possible to record sleep in the home
technical equipment necessary for polysomnography environment as well. Because FNE at home have not
(PSG). FNE include a prolonged sleep latency (SL), been reported frequently with good sleepers (5,6), it
shorter total sleep time (TST), reduced sleep efficiency has been argued that an adaptation night may not be
(SE), more time awake during the night (wake after necessary (6,7). This view was supported in a recent
sleep onset; W ASO), a larger percentage of stage 1 report by Wauquier et al. (8), who studied healthy
sleep, and a delay in the onset of the first period of males and females over 88 years of age, although the
rapid eye movement (REM) sleep on the initial night same authors had observed FNE in an earlier study
of an all-night PSG recording when compared to sub- (9). Edinger et al. (10) found no systematic FNE in a
sequent nights of PSG recording (1-4). group of elderly subjects with difficulties in initiating
and maintaining sleep (DIMS), but they pointed out
Accepted for publication July 1996. that inspection of the data from each individual subject
Address correspondence and reprint requests to Bernd Saletu, showed that half of the sample did experience multiple
MD., Department of Psychiatry, University of Vienna, Wahringer FNE. It seems that FNE vary with the type of sleep
Giirtel 18-20, A-1090 Vienna, Austria.
Presented at the 12th Congress of the European Sleep Research disorder, and similar studies in different patient groups
Society, Florence, Italy, May 22-24, 1994. have yet to be conducted.
691
692 B. SALETU ET AL.

First-night effects have been described in previous Anxiety Rating Scale (HAM-A) (17). The exclusion
literature as a phenomenon related solely to PSG. In criteria included pregnant or lactating women; women
our opinion, changes in subjectively experienced sleep of child-bearing age who were not practicing adequate
quality and awakening quality, as well as in objective- contraceptive methods; insomnia secondary to nocturia
ly evaluated awakening quality, must also be consid- or pain; patients with a history of benzodiazepine hy-
ered when regarding FNE as an adaptation effect. FNE persensitivity; patients with any significant medical
might reflect a patient's ability to adapt to a new sit- disorder; patients with a history of drug abuse or ha-
uation (8) and may therefore be pertinent diagnostic bituation, including alcohol; patients requiring psycho-
and therapeutic issues (1). active medication or/and other drugs that might have
The aim of this current investigation was to study interfered with the study assessments; patients who
FNE in generalized anxiety disorder (GAD) patients were unable or unwilling to comply with the protocol;
with complaints of insomnia, using PSG and a psy- patients who worked at night; and patients with nar-
chometric test battery to assess subjective and objec- row-angle glaucoma. The study was performed in ac-
tive sleep and awakening quality, either in the sleep cordance with the rules and regulations for the conduct
laboratory or at home. To our knowledge, this is the of clinical trials stated in the Declaration of Helsinki,
first sleep study in insomniac GAD patients that in- as revised by the World Medical Assembly in Tokyo
cludes data from home recordings. and Venice. The protocol passed the Ethical and Sci-
entific Review Committee of the host institutions. An
informed written consent was obtained.
METHODS
All patients had been free of drugs for at least 2
Subjects weeks before the sleep recordings. The L group in-
cluded 8 males and 14 females with an age range of
Within the framework of a psychopharmacological 25-64 years [mean 27.0, standard deviation (SD) 8.2],
study on the differential effects of short-versus long- with a mean SAS score of 39.8 (SD 5.7) and a mean
half-life benzodiazepines (2), the FNE in GAD were HAM-A score of 27.0 (SD 8.2). The H group consisted
investigated either in the sleep laboratory (L group; n of 10 males and 7 females with an age range of 32-
= 22) or in the home environment (H group; n = 21) 64 years (mean 30, SD 6.9), with a mean SAS score
utilizing an ambulatory Oxford Medilog 9000 PSG of 41.4 (SD 6.8) and a mean HAM-A score of 30 (SD
system (Oxford Medical Ltd., Abingdon, England). 7.0). There were no significant intergroup differences
Due to technical problems, data from four adaptation in regard to age, gender, or SAS and HAM-A scores.
nights in the H group were lost. See Saletu et al. (12) for further details.
The diagnostic classification of each subject was de-
termined by an experienced sleep specialist based on
Polysomnography
a thorough clinical exploration according to the diag-
nostic classification systems in use at the time of the All-night PSG recordings were obtained between
study. For these subjects, the ICD-9 code (13) was 10.30 p.m. (lights out) and 6.00 a.m. (buzzer or alarm
307.42-1 (non-organic insomnia) based on a mild clock), either in two identically shielded rooms in the
GAD (300.0); the diagnosis according to the Associ- sleep laboratory (L group) or at home, using a portable
ation of Sleep Disorders Centers (14) classification Oxford Medilog 9000 PSG system (H group), on two
was "disorder of initiating and maintaining sleep" consecutive nights. Thus, the total time in bed (TIB)
(DIMS) with symptoms and personality disorders. Ac- was fixed. Research has demonstrated the usefulness
cording to the most current American Sleep Disorders of the Medilog PSG system in the diagnostic evalua-
Association manual (15), this diagnosis would corre- tion of patients with DIMS (10,18,19) and GAD (12).
spond to ICSD code 300.02-"Sleep disorder associ- The last study (12) also showed that the Medilog PSG
ated with GAD". system produces technically acceptable recordings in
The 39 outpatients included in the study met at least most patients and is generally well tolerated.
two of the four following criteria on an average of 4 Electrodes were attached according to the interna-
nights per week for at least 3 months: SL of 2:45 min- tional 10/20 system. In addition to the electroenceph-
utes; two or more nocturnal awakenings, with diffi- alographic (EEG) channels, C4-Al, 02-Al, and
culties in getting back to sleep; early morning awak- Cz-02, two electrooculographic (EOG) channels and
ening; and TST <6 hours per night. the submental electromyogram (EMG) were recorded.
Patients also had to suffer from a mild to moderate In the L group, PSG recordings were carried out uti-
degree of anxiety, defined as a total score of 33 or lizing a Nihon-Kohden (Tokyo, Japan) polygraph.
more on the Zung Self Rating Anxiety Scale (SAS) Four channels (Cz-02, EMG, and two EOG) were also
(16) and a total score of 18 or above on the Hamilton recorded using a Hewlett Packard 3968 tape recorder
Sleep, Vol. 19, No.9, 1996
I
~,
FIRST-NIGHT EFFECTS ON GAD 693
I

(Hewlett Packard, San Diego, CA). In the H group, tal score), and attention variability (AD/SV, difference
four channels (Cz, 02, EMG, and two EO G) were re- between extreme scores) (25); the numerical memory
corded on 60-minute audio cassette tapes (Medilog test (25); and the Griinberger fine motor activity test
PSG system) and had to be played back utilizing a (right and left hand) for evaluation of changes in psy-
Beckmann R-6ll polygraph (Beckmann Instruments, chomotor activity and drive (25). Reaction time, re-
Schiller Park, IL) and the Scanner 9000 (Oxford Med- action time variability (in milliseconds), and the errors
ical Ltd., Abingdon, England) as an interface. Thirty- of omission and commission were determined by a
second epochs were scored visually according to the computer-assisted reaction time apparatus. See Grtin-
criteria of Rechtschaffen and Kales (20). Sleep prints berger et al. (26) for a more detailed description of the
and variables were obtained by means of a Hewlett psychometric test battery.
t' Packard Vectra computer system (21).
I
Psychophysiological data
Dependent variables Psychophysiological investigations included the
Sleep initiation and maintenance critical flicker frequency (descending threshold) after
awakening. Muscle strength of the right and left hand
Total sleep time (TST) is the amount of actual sleep and of the right and left index finger and thumb were
time within the total sleep period (TSP). TSP is the evaluated by means of the vigorimeter (kp/cm2) (27).
period of time measured from sleep onset until the Moreover, evening and morning pulse rate as well as
final awakening. In addition to TST, TSP includes in- systolic and diastolic blood pressure were obtained.
termittent wake time (WASO) and movement time Objective and subjective awakening quality were in-
(MT). The number of awakenings refers to the arousals terpreted in the framework of Stransky'S concept of
to wakefulness during TSP. Wake before buzzer (wake noopsyche and thymopsyche (28). He defined the
after final awakening; WAFA) is the time between the noopsyche as characterized by intellectual and mnestic
final awakening in the morning and time that the buzz- functions, whereas the thymopsyche includes mood,
er or alarm clock goes off. The SE index is the pro- drive, and affectivity. This concept has proven its use-
portion of sleep in the recorded period, calculated by fulness in psychopharmacological research (e.g. "noo-
dividing TST by the total TIB (fixed in our study) tropics", "thymoleptics").
multiplied by 100.

r' Statistical analysis


Sleep architecture
In order to verify a normal distribution of data, all
Sleep stages 1, 2, 3, 4, and REM are expressed in dependent variables were tested by means of multiple
percentages of the TST. REM latency is defined as the Kolmogorov-Smirnov tests. A multivariate analysis of
time from the first epoch of stage 2 sleep to the first variance (MANOVA) for repeated measurements was
REM period of at least 3 minutes (22). Stage shifts performed, including normally distributed variables to
r'
refer to the number of shifts from one stage to another identify group effects (laboratory vs. home record-
during the TIB. ings), night effects (first vs. second night), and possible
interactions of recording condition and night of re-
cording (i.e. differential adaptation effects).
Subjective sleep and awakening quality Descriptive statistical analysis was carried out on
After the morning toilet, patients completed the SSA changes in various clinical, PSG, and psychometric
(23), a self-assessment scale for the evaluation of sleep variables as well as differences between the changes
and awakening quality. The von Zerssen B-S scale in the two groups. Changes between the first and sec-
(24) was completed for evaluation of well-being in the ond night in GAD patients recorded either in the lab-
evening and in the morning. Drive, mood, affectivity, oratory (L group) or at home (H group) were evaluated
and drowsiness were measured by means of 100-mm by the Wilcoxon test; differences between changes in
visual analogue scales (VAS). both groups were calculated by means of the Mann
Whitney U-test.

Objective awakening-quality
RESULTS
Subsequently, the patients participated in a series of
Multivariate analysis of variance
psychometric tests: the Griinberger alphabetical cross-
out test for quantification of attention (AD/total score), To study possible FNE in insomniac GAD patients
concentration (ADIE%, errors in percentage of the to- and the influence of the recording environment (sleep
Sleep. Vol. 19. No.9. 1996
694 B. SALETU ET AL.

TABLE 1. First-night effects in laboratory and home recordings concerning sleep initiation and maintenance and sleep
architecture in insomniac generalized anxiety disorder (GAD) patients

Laboratory (n = 22) Home (n = 17)


Variable First night Second night Change First night Second night Change
Sleep latency (minutes) 41 (43) 26 (57) -15" 57 (49) 36 (30) -21
WASO (minutes) 82 (65) 72 (58) -10 105 (77) 71 (51) -34
WAFA (minutes) 14 (24) 9 (26) -5 15 (22) 6 (9) -9
Number of awakenings 10 (6) 8 (4) -2 7 (4) 8 (4) I
Total sleep period (minutes) 390 (52) 409 (83) 196 373 (60) 404 (31) 31
Total sleep time (minutes) 305 (90) 334 (94) 29 267 (98) 331 (66) 646
Sleep efficiency (%) 69 (20) 75 (21) 6 60 (23) 74 (14) 14 a
Stage I sleep (%) 13 (10) 10 (10) -3 10 (9) 7 (5) -3
Stage 2 sleep (%) 58 (10) 52 (14) -6 49 (8) 45 (8) -4
Stage 3 sleep (%) 8 (6) 12 (10) 4 12 (5) 14 (7) 2
Stage 4 sleep (%) 6 (8) 6 (6) 0 10 (6) 13 (6) 3
Stage 3/4 sleep (%) 14 (11) 18 (10) 4 22 (9) 27 (7) 5
REM sleep (%) 15 (7) 20 (9) 5 20 (7) 20 (5) 0
Movement time 2 (2) 3 (2) 1 (2) 2 (2) 1"
REM latency (minutes) 140 (86) 121 (70) -19 130 (74) 117 (61) -]3

Stage shifts 56 (19) 55 (19) -1 42 (16) 51 (17) 9"


Data are given as means and standard deviations (SD). WASO, wake after sleep onset; WAFA, wake after final awakening; REM, rapid
eye movement.
"p < 0.05 (Wilcoxon test).
6 p < 0.01 (Wilcoxon test).

laboratory vs. home recording), we used a MANOVA Objective awakening quality. In the morning follow-
for repeated measures. The Kolmogornov-Smirnoff ing night 2, we found significant group-by-night ef-
tests revealed a normal distribution of all variables, fects, with higher scores in attention (total score) and
with the exception of SL, WAFA, TSP, MT, concen- fine motor activity (right hand and right plus left hand)
tration (number of errors), and reaction time (errors of and a decrease in attention variability in the L group.
omission). The same variables showed an inverted pattern in the
H group.
Psychophysiological data. We observed a signifi-
Night effects: first vs. second night
cant group/night interaction (p < 0.05) in evening di-
For the whole group of 39 patients, we found that, astolic blood pressure, with a significant decrease from
concerning sleep initiation and maintenance, TST and the first to the second night in the L group and no
SE increased from the first to the second night (p < changes in the H group. Muscle strength of the left
0.01), whereas in sleep architecture, there was a sig- hand decreased only in the H group, whereas there
nificant (p < 0.01) decrease in stage 2 sleep percent- were no changes in the L group.
age. On the other hand, slow-wave sleep (stage 3,
stage 4, and stage 3/4 sleep, and stage 3/4 sleep per-
Descriptive statistical analysis
centage) and REM sleep duration were significantly
elevated on night 2. Furthermore, REM latency was Regarding sleep initiation and maintenance, TST
shorter on night 2 (p < 0.05). was reduced on the first night as compared with the
Objective awakening quality.-Whereas attention second in both the Land H groups of GAD patients,
(total score) was reduced in the morning after the sec- with statistical significance obtained in the H group
ond night, performance in reaction time (errors of (Table 1). SL (early insomnia), WASO (middle insom-
commission) improved. nia), and WAFA (late insomnia) values were longer on
the first night in both patient groups. The number of
Group-by-night interaction awakenings was higher on the first night only in the
L group, but not in the H group. The SE percentage
Sleep initiation and maintenance. There was a sig- was reduced on the first night in both groups, with
nificant (p < 0.05) group-by-night effect in the number statistical significance obtained in the H group.
of awakenings, with an increase from the first to the Sleep architecture showed a higher stage 1 and 2
second night in the H group and a decrease in the L sleep percentage on the first night compared to the
group. second in both groups, with statistical Significance for
Sleep, Vol. 19, No.9, 1996
FIRST-NIGHT EFFECTS ON GAD 695

TABLE 2. First-night effects in laboratory and home recordings concerning objective and subjective sleep and awakening
quality in insomniac generalized anxiety disorder (GAD) patients

Laboratory (n = 22) Home (n = 17)


Variable First night Second night Change First night Second night Change
Sleep quality (score) 18 (5) 16 (6) -2 21 (6) 18 (5) -3
Awakening quality (score) 17 (5) l7 (6) 0 l7 (5) 18 (7) I
Somatic complaints (score) 7 (2) 7 (2) 0 7 (2) 8 (3) I
Total SSA score 42 (10) 39 (11) -3 44 (II) 44 (I) 0
Well-being evening (score) 15 (13) 21 (12) 6 19 (14) 21 (13) 3
Well-being morning (score) 20 (14) 17 (12) -3 20 (15) 22 (15) 2
Drive (score) 51 (32) 43 (26) -8 47 (32) 50 (31) 3
Mood (score) 60 (27) 56 (26) -4 63 (29) 59 (23) -4
Affectivity (score) 60 (25) 68 (18) 8 60 (23) 55 (29) -5
Drowsiness (score) 54 (32) 56 (30) 2 61 (33) 58 (33) -3
Attention (score) 536 (133) 540 (127) 4 570 (101) 508 (107) -62 b
Concentration (score) 498 (170) 521 (127) 23 520 (164) 493 (102) -27
Errors 38 (103) 19 (11) -19 50 (116) 21 (15) -29
Errors (%) 3 (2) 4 (2) I 4 (3) 4 (3) 0
Attention variability (n) 15 (4) l4 (5) -1 13 (5) 16 (6) 3
Numerical memory (n) 5 (1) 5 (2) 0 6 (2) 6 (2) 0
Fine motor activity (right) (n) 40 (6) 43 (7) 3" 44 (8) 42 (9) -2
Fine motor activity (left) (n) 27 (8) 29 (7) 2 31 (7) 30 (8) -1
Fine motor activity
(right + left) (n) 68 (11) 72 (12) 4" 76 (14) 72 (16) -4
Reaction time (RT) (milliseconds) (msec) 572 (101) 538 (151) -33 540 (105) 534 (109) -6
RT variability (milliseconds) 112 (59) 88 (54) -24 L05 (46) 110 (35) 2
RT, errors of commission (n) 5 (4) 2 (2) -3 6 (5) 3 (3) -3 b
RT, errors of omission (n) 1 (1) 1 (1) -0 I (1) 0(1) -I
Data are given as means and SD.
" p < 0.05 (Wilcoxon test).
b p < 0.0l (Wilcoxon test).

stage 2 sleep percentage obtained in the L group (Table from the first to the second morning in the L group,
1). On the other hand, the stage 3/4 percentages were whereas the H group exhibited the opposite tendencies.
lower on night 1 in both the Land H group. REM The differences between the two groups reached the
sleep percentage was significantly lower on night I level of statjstical significance. On the other hand, re-
than night 2 in the L group, whereas in the H group action time and errors of commission decreased in
it remained stable. REM latency was longer on night both groups significantly.
I in both groups. MT was shorter on the first night in Psychophysiological measures showed that systolic
both groups; the difference reached statistical signifi- and diastolic blood pressure on the evening of night I
cance only in the H group. The number of stage shifts were significantly higher than on the following eve-
was slightly higher on night 1 than night 2 in the L ning in the L group, whereas in the H group there were
group, but it was significantly lower on the first night no significant changes. Thus the intergroup differences
than on the second night in the H group. were significant (Table 3).
Subjective sleep and awakening quality measures,
based on the total score of the SSA, were similar on
DISCUSSION
the two subsequent nights in both groups (Table 2).
The thymopsyche, rated by means of the von Zers- Our study demonstrated that GAD patients com-
sen well-being scale, showed better values on the eve- plaining of DIMS exhibited indications of FNE in both
ning of night I, preceding the recordings, than on night laboratory and home PSG. These include: lower TST
2 in both groups (Table 2). However, after morning and lower SE, higher stage 2 sleep percentage, reduced
awakenings, home-recorded GAD patients felt better deep sleep (percentage and duration), shorter duration
after the first than after the second night. of REM sleep, and a prolonged REM latency.
Noopsychic variables, measured objectively by Except in the variable "number of awakenings" (in-
means of a psychometric test battery, showed signifi- creased in the H group and decreased in the L group
cantly better performance in "attention" after the first from the first to the second night), the MANOVA re-
compared to the second night in the H group only vealed no group-by-night interactions concerning
(Table 2). Fine motor activity improved significantly PSG. These results confirm previous reports by Ware
Sleep, Vol. 19, No.9, 1996
696 B. SALETU ET AL.

TABLE 3. First-night effects in laboratory and home recordings concerning psychophysiological data in insomniac
generalized anxiety disorder (GAD) patients

Dif-
Laboratory (n = 22) Home (n = 17)
ference
First Second First Second between
Variable night night Change night night Change changes
Critical flicker frequency (Hz) 37.2 (5.4) 36.7 (2.9) -0.5 38.5 (2.9) 38.5 (2.3) 0.0
Vigorimeter (right finger) (kp/cm') 0.4 (0.1) 0.5 (0.1) 0.1 0.5 (0.1) 0.5 (0.1) -0.0
Vigorimeter (left finer) (kp/cm2) 0.4 (0.1) 0.4 (0.0) 0.0 0.5 (0.1) 0.5 (0.1) 0.0
Vigorimeter (right hand) (kp/cm2) 0.7 (0.2) 0.7 (0.2) 0.0 0.7 (0.1) 0.7 (0.1) -0.0
Vigorimeter (left hand) (kp/cm2) 0.7 (0.1) 0.7 (0.2) 0.0 0.7 (0.2) 0.6 (0.1) -O.lb
Evening systolic BP (mm Hg) 120 (21) 107 (31 ) -13 b 123 (18) 128 (20) 5
Evening diastolic BP (mm Hg) 77 (10) 69 (19) -8 a 82 (9) 85 (10) 3
Evening pulse (bpm) 69 (8) 70 (8) 1 71 (10) 70 (II) -1
Morning systolic BP (mm Hg) 113 (18) 108 (32) -5 121 (19) 121 (16) 0
Morning diastolic BP (mm Hg) 75 (II) 72 (20) -3 83 (11) 83 (II) 0
Morning pulse (bpm) 68 (8) 69 (8) 1 70 (10) 71 (9) 1
Data are given as means and SD. BP, blood pressure; bpm, beats per minute.
a p < 0.05 (Wilcoxon test).
b p < 0.01 (Wilcoxon test).
c p < 0.05 (Mann-Whitney U test).

d p < 0.01 (Mann-Whitney U test).

(29) and Edinger et al. (10) and suggest that many Concerning the noopsyche, we found only a few
DIMS patients with GAD may manifest FNE even FNE in attention and reaction time (errors of commis-
when recorded at home with ambulatory monitors. sion), indicating few or no adaptation effects on ob-
It may be argued that FNE result from anxiety per jective awakening quality. This result was surprising
se. In this case, GAD patients may show fewer because we also expected some FNE on the noopsyche
changes in their sleep from the first to the second (i.e. improvement in cognitive performance) when ob-
night, because their sleep, already affected by their serving the whole sample of GAD patients.
anxiety, would have little room to change in the di- Looking at the Land H groups separately for re-
rection of anxiety ("ceiling effect"). The findings of vealing FNE, we did find various interactions; al- .,
Reynolds et al. (30) support this view, because GAD though they improved in attention and fine motor ac-
outpatients had less FNE than a group of depressed tivity from the first to the second morning, they de-
patients. Akiskal et al. (31) reported difficulties in ini- teriorated at home.
tiating and maintaining sleep in a mixed sample of For psychophysiological variables, we found no
anxious depressed patients, including some patients FNE for the whole sample, but again there were group-
with generalized anxiety, but not in a comparison
by-night interactions for systolic and diastolic BP mea-
group with dysthymic disorders, in which DIMS was
sured in the evening and for the vigor of the left hand.
most pronounced in the first night. Because of these
In the L group, patients showed a significant decrease
FNE, Akiskal et al. (31) proposed that adaptation dif-
in blood pressure in the evening from the first to the
ficulties were characteristic of this anxious group.
second night, whereas there was no such adaptation
Although PSG demonstrated a typical pattern of
FNE, it was interesting that we found no changes in effect in the H group. This may suggest that the pa-
subjectively experienced sleep quality. It might be pos- tients feel more taken care of in the laboratory envi-
sible that self-rated sleep quality is also determined by ronment.
factors that are not associated with FNE. Edinger et In conclusion, our findings demonstrate that many
al. (10) noted that several scales from the Minnesota GAD patients manifest FNE even when studied at
Multiphasic Personality Inventory (MMPI) were able home with ambulatory recording, in contrast to young,
to discriminate between those patients who showed healthy volunteers showing no FNE when recorded at
mUltiple FNE and those who did not. home (5,6). Therefore it is necessary to record an ad-
In subjective awakening quality (the thymopsychic aptation night in ambulatory PSG when studying GAD
variables well-being, mood, drive, drowsiness, and af- patients. Because FNE can be regarded as indicators
fectivity), no differences were found between the first of a subject's ability to adapt to a new environment or
and the second night. This could mean that patients situation (8), it is important to consider PSG data from
with GAD feel bad all of the time regardless of the the first night as well. This is also of interest in light
environment. of the fact that in many previous sleep EEG studies,
Sleep, Vol. 19, No.9, 1996
" FIRST-NIGHT EFFECTS ON GAD 697

including those with GAD patients, sleep recordings long- vs. a short-half-life benzodiazepine (quazepam vs. tria-
zolam). Neuropsychobiology 1994;29:69-90.
were not obtained on the adaptation night (32-34). 13. World Health Organization. Manual of the International Statis-
The fact that our sample of GAD patients showed tical Classification of Diseases, Injuries and Causes of Death-
9th revision. Geneva: World Health Organization, 1977.
only few adaptation effects in regard to subjective 14. Association of Sleep Disorders Centers. Diagnostic classifica-
sleep quality and noopsychic and thymopsychic vari- tion of sleep and arousal disorders. Sleep 1979;2:1-137.
ables does not mean that these parameters would be 15. Diagnostic Classification Steering Commitee, Thorpy MJ, chair-
man. International classification of sleep disorders: diagnostic
manifest as adaptation effects in other sleep-disturbed and coding manual. Rochester, MN: American Sleep Disorders
patient groups and normal controls subjects. Association, 1990.
Because the final word on FNE cannot be written 16. Zung WK. A rating instrument for anxiety disorders. Psycho-
somatics 1971;12:371-9.
until data on subjective and objective sleep quality 17. Hamilton M. The assessment of anxiety states by rating. Br Med
have been obtained from populations of various di- Psvchol 1959;32:50-5.
agnostic entities, further empirical investigations, even 18. A~coli-Israel S, Kripke OF, Mason W, Messin S. Comparison
of home sleep recordings and polysomnography in older adults
considering personality dimensions and environmental with sleep disorders. Sleep 1981 ;4:283-91.
factors, are necessary. 19. Edinger JD, Hoelscher TJ, Webb MD. Marsh GR, Radtke RA,
Erwin CWo Polysomnographic assessment of DIMS: empirical
evaluation of its diagnostic value. Sleep 1989; 12:315-22.
Acknowledgements: Funding for the visit and collabo- 20. Rechtschaffen A. Kales A. A manual of standardized terminol-
" ration of P.U. was provided by the Exchange Fellow Program ogy, technique and scoring system for sleep stages of human
of the Ministry of University Affairs in Thailand and the subject. Los Angeles: Brain Information Service, University of
California, 1968.
Ministry of Science and Research in Austria. We express 21. Saletu B, Anderer P, Frey R, Krupka M, Klosch G. Zur Neu-
our appreciation of this program, and we thank Mrs. Dawn rophysiologie des Schlafes. Some remarks about the neuro-
Eckelhart and the entire staff of the Division of Pharmaco- physiology of sleep. Psychiatria Danubina 1991;3:31-58.
psychiatry and Sleep Research of the Department of Psy- 22. Reynolds CF, Taska LS, Jarret DB, Coble PA, Kupfer OJ. REM
latency in depression: is there one best definition? Biol Psychi-
chiatry, School of Medicine, University of Vienna, Austria,
atry 1983;18:849-63.
for their valuable assistance in this project. 23. Saletu B, Wessely P, Gliinberger J, Schultes M. Erste klinische
Erfahrungen mit einem neuen schlafanstoBenden Benzodiaze-
pin, Cinolazepam, mitteIs eines SeIbstbeurteilungsbogens fUr
REFERENCES Schlaf- und Aufwachqualitiit (SSA). Neuropsychiatrie 1987; I:
169-76.
24. Von Zerssen 0, Koeller OM, Rey ER. Die Befindlichkeitsskala
1. Rechtschaffen A, Verdone P. Amount of dreaming: effect of (B-S)--ein einfaches Instrument zur Objektivierung von Befin-
incentive and adaptation to laboratory and individual differ- dlichkeitsstorungen, insbesonders im Rahmen von Liingsschn-
ences. Percept Mot Skills 1964;19:947-58. ittuntersuchungen. Arzneim Forsch Drug Res 1970;20:915-8.
r' 2. Agnew HW, Webb WB, Williams RL. The first night effect: an 25. Griinberger J. Psychodiagnostik des Alkoholkranken. Ein meth-
EEG study of sleep. Psychophysiology 1966;2:263-6. odischer Beitrag zur Bestimmung der Organizitdt in der Psy-
3. Mendel J, Hawkins DR. Sleep laboratory adaptation in normal chiatrie. Wien: Maudrich; 1977.
subjects and depressed patients ("first night effect"). Electroen· 26. Griinberger J, Linzmayer L, Dietzel M, Saletu B. The effect of
cephalogr Clin Neurophysiol 1967;22:536--8. biologically-active light on the noo- and thymopsyche and on
4. Schmidt HS, Kaelbling R. A differential laboratory adaptation psychophysiological variables in healthy volunteers. Int J Psy-
of sleep parameters. Biol Psychiatry 1971;3:33-45. chophysiol 1993;15:27-37.
5. Coates TJ, George JM, Killen JD, Marchini E, Hamilton S, 27. Fiinfgeld EW. Vigorimeter: Zur Kraftmessung der Hand und zur
Thorensen CE. First night effects in good sleepers and sleep Simulationspliifung. Dtsch Med Wochenschr 1966;49:2214-6.
maintenance insomniacs when recorded at home. Sleep 1981 ;4: 28. Stransky E. Uber die Dementia praecox. Streifziige durch Klinik
293-8. und Psychopathologie. Wiesbaden: Bergmann, 1909.
6. Sharpley AL, Solomon RA, Cowen PJ. Evaluation of first night 29. Ware JC. Sleep and anxiety. In: Williams RL, Karacan I, Moore
effect using ambulatory monitoring and automatic sleep stage CA, eds. Sleep disorders: diagnosis and treatment. New York:
analysis. Sleep 1988;11:273-6. John Wiley & Sons, 1988:189-214.
7. Coble P, McPartland RJ, Silva WJ, Kupfer OJ. Is there a first 30. Reynolds CF, Shaw PH, Newton TF, Coble PA, Kupfer OJ. EEG
night effect? (a revisit). Bioi Psychiatry 1974;9:215-9. sleep in outpatients with generalized anxiety: a preliminary
8. Wauquier A, Van Sweden B, Lagaay AM, Kemp B, Kamphu- comparison with depressed outpatients. Psychiatry Res 983;8:
isen HAC. Ambulatory monitoring of sleep-wakefulness pat- 81-9.
terns in healthy elderly males and females (> 88 years): the 31. Akiskal HS, Lemmi H, Dickson H, King 0, Yerevanian B, Van
"Senieur" protocol. JAm Geriatr Soc 1992;40:109-114. Valkenburg C. Chronic depression, part 2: sleep EEG differen-
9. Wauquier A, Van Sweden B, Kerkhof GA, et al. Ambulatory tiation of primary dysthymic disorders from anxious depression.
first night sleep effect recording in the elderly. Behav Brain Res J Affect Disord 1984;6:287-95.
1991 ;42:7-11. 32. Papadimitriou GN, Kerkhofs M, Kempenaars C. Mendelwicz 1.
10. Edinger JD, Marsh GR, McCall WV, Erwin Cw, Lininger AW. EEG sleep studies in patients with generalized anxiety disorder.
Sleep variability across consecutive nights of home monitoring Psychiatry Res 1988;26: 183-90.
in older mixed DIMS patients. Sleep 1991;14:13-7. 33. Papadimitriou GN, Linkowski P, Kerkhofs M, Kempenaars C,
11. Hauri PJ, Olmstead EM. Reverse first night effect in insomnia. Mendelwicz J. Sleep EEG recordings in generalized anxiety dis-
Sleep 1989;12:97-105. order with significant depression. J Affect Disord 1988;15:113-8.
12. Saletu B, Anderer P, Brandstiitter N, et al. Insomnia in gener- 34. Arriaga F, Paiva T. Clinical and EEG sleep changes in primary
alized anxiety disorder: polysomnographic, psychometric and dysthymia and generalized anxiety: a comparison with normal
clinical investigations before, during and after therapy with a controls. Biol Psychiatry 1990;24: 109-14.

Sleep, Vol. /9, No.9, 1996

Potrebbero piacerti anche