Polysomnographic and Actigraphic Evidence of Sleep Fragmentation in Patients with Irritable Bowel Syndrome
Abstract
To characterize the function and quality of sleep in patients with irritable bowel syndrome (IBS).
A prospective study with a historic comparison group.
A regional hospital that also serves as a tertiary referral center.
Eighteen patients with IBS and a comparison group of 20 matched adults with mild benign snoring.
A polysomnography study and a wrist actigraphy study.
All subjects underwent sleep studies and completed self-report questionnaires (IBS severity, psychosocial variables, sleep function, and Epworth Sleepiness Scale). Fourteen IBS and 11 comparison patients underwent actigraphy.
The IBS patients had more than 70% less slow-wave stage sleep (4.5 +/- 7.3% vs 19.3 +/- 12.9%; P = 0.006), compensated by increased stage 2 sleep (72.2 +/- 6.6% vs 60.1 +/- 16.8%; P = 0.01). The IBS group had significant sleep fragmentation with a significantly higher arousal and awakening index (P < 0.001), a longer wake period after sleep onset (P = 0.02), and more downward shifts to lighter sleep stages (P = 0.01). The 4-night actigraphy study supported the polysomnography findings. The sleep fragmentation index was significantly higher (P = 0.008) in the IBS group. The IBS patients reported greater daytime sleepiness (9.0 +/- 4.8 vs 6.4 +/- 4.8, Epworth Sleepiness Scale score, P < 0.01) and greater impairment in quality of life, which correlated significantly with the sleep fragmentation indexes. The difference between the groups was not due to differences in baseline anxiety/depression levels.
Patients with IBS have impaired sleep quality, reduced slow-wave sleep activity, and significant sleep fragmentation. The cause-and-effect relationship of these findings with patients' daytime symptoms should be studied further.
INTRODUCTION
IRRITABLE BOWEL SYNDROME (IBS), AS DEFINED IN THE
ROME CRITERIA, IS CHARACTERIZED BY CHRONIC, RECUR-
RING ABDOMINAL DISCOMFORT OR PAIN WITH IMPAIRED
BOWEL HABITS THAT CANNOT BE EXPLAINED BY STRUC-
TURAL OR BIOCHEMICAL ABNORMALITIES.1The symptoms
fluctuate over time and are associated with a serious impairment of qual-
ity of life.2Irritable bowel syndrome is the most common diagnosis
made by gastroenterologists in the United States, with a lifetime preva-
lence ranging from 8% to 20% among adults.3,4 The rates are affected by
nationality and culture as well as research methodology and diagnostic
criteria, which explain the large range of values.
Poor sleep quality and insomnia are commonly reported in IBS
patients. This sleep impairment may be related to patients’ symptoms,
although the cause-and-effect relationship is not clear. Kumar et al5
reported an increased proportion of rapid eye movement (REM) sleep in
a sample of IBS patients who underwent nocturnal polysomnography
(PSG), without a change in the sleep latency period or the number of
REM episodes. Orr et al6confirmed these findings in 10 women with
IBS and reported a significant increase in the percentage and duration of
REM sleep. However, findings regarding REM sleep are not consistent.
Some investigators7have reported a longer latency to REM with no sig-
nificant differences in the REM period itself. Others8have concluded
that IBS patients do not have any significant PSG abnormalities. Thus,
there is no definitive evidence to date in support of the hypothesis that
changes in the REM cycle are responsible for sleep impairment in IBS.
Despite the inconsistency of PSG findings, IBS patients are consid-
ered to be “poor sleepers” based on subjective reporting. Women with
IBS report more nocturnal awakenings, general restlessness during
sleep, and overall disturbed sleep.7Using a sleep diary, Goldsmith and
Levin9tested the hypothesis that IBS symptoms are related to distur-
bances in sleep. They found that poor sleep function was associated with
an exacerbation of IBS symptoms the following day, a conclusion that
has been supported by others.10
Sleep disruption can lead to impairment of nocturnal and daily func-
tioning, (ie, deterioration of sleep, excessive daytime sleepiness, and
deterioration in quality of life11) all commonly reported in IBS patients.
Little is known about sleep fragmentation in IBS patients. Previous stud-
ies have found no differences in indexes of disrupted sleep between IBS
patients and controls.8,10
Actigraphy (activity-based sleep monitoring) is used to measure the
sleep-wake schedule and sleep quality in the subject’s natural sleeping
environment.12 It is not a primary diagnostic tool nor a tool to determine
sleep stages. It can serve as a useful adjunct to confirm sleep patterns
observed in standard PSG.13 Actigraphy has not been used in the study
of sleep patterns and quality in IBS.
We characterized sleep patterns of IBS patients compared to a control
group, using self-administered questionnaires on IBS symptoms and
sleep habits, a nocturnal PSG study, and actigraphy. We also assessed the
potential confounding effect of factors such as age, sex, and baseline
level of anxiety/depression on sleep quality.
Sleep Fragmentation in Patients with Irritable Bowel Syndrome—Rotem et al
SLEEP, Vol. 26, No. 6, 2003 1
Polysomnographic and Actigraphic Evidence of Sleep Fragmentation in Patients
with Irritable Bowel Syndrome
SLEEP IN MEDICAL DISORDERS
Amit Y Rotem, MD1,2; Ami D Sperber, MD, MSPH2; Pavel Krugliak, MD2; Bruria Freidman, REEGT1; Asher Tal, MD1,3; Ariel Tarasiuk, PhD1,4
*This study was conducted in partial fulfillment of requirements for an MD degree.
Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel—1Sleep-wake Disorders
Unit; 2Department of Gastroenterology; 3Department of Pediatrics B; 4Department of Physiology
Study Objective: To characterize the function and quality of sleep in
patients with irritable bowel syndrome (IBS).
Design: A prospective study with a historic comparison group.
Setting: A regional hospital that also serves as a tertiary referral center.
Patients: Eighteen patients with IBS and a comparison group of 20
matched adults with mild benign snoring.
Interventions: A polysomnography study and a wrist actigraphy study.
Measurements: All subjects underwent sleep studies and completed self-
report questionnaires (IBS severity, psychosocial variables, sleep func-
tion, and Epworth Sleepiness Scale). Fourteen IBS and 11 comparison
patients underwent actigraphy.
Results: The IBS patients had more than 70% less slow-wave stage
sleep (4.5±7.3% vs 19.3±12.9%; P=0.006), compensated by increased
stage 2 sleep (72.2±6.6% vs 60.1±16.8%; P=0.01). The IBS group had
significant sleep fragmentation with a significantly higher arousal and
awakening index (P<0.001), a longer wake period after sleep onset
(P=0.02), and more downward shifts to lighter sleep stages (P=0.01). The
4-night actigraphy study supported the polysomnography findings. The
sleep fragmentation index was significantly higher (P=0.008) in the IBS
group. The IBS patients reported greater daytime sleepiness (9.0±4.8 vs
6.4±4.8, Epworth Sleepiness Scale score, P<0.01) and greater impair-
ment in quality of life, which correlated significantly with the sleep frag-
mentation indexes. The difference between the groups was not due to dif-
ferences in baseline anxiety/depression levels.
Conclusions: Patients with IBS have impaired sleep quality, reduced
slow-wave sleep activity, and significant sleep fragmentation. The cause-
and-effect relationship of these findings with patients’ daytime symptoms
should be studied further.
Key Words: Sleep, irritable bowel syndrome, polysomnography, actigra-
phy, fragmented sleep
Citation: Rotem AY; Sperber AD; Krugliak P et al. Polysomnographic and
actigraphic evidence of sleep fragmentation in patients with irritable bowel
syndrome. SLEEP 2003;26(6):?-?.
Disclosure Statement
No significant financial interest/other relationship to disclose.
Submitted for publication December 2002
Accepted for publication April 2003
Address correspondence to: Ami D. Sperber, MD, MSPH, Department of
Gastroenterology, Soroka University Medical Center, Beer-Sheva, Israel 84101;
Tel: 972-8-6400251; Fax: 972-8-6233083; E-mail: amy@bgumail.bgu.ac.il
METHODS
Study Population
Twenty patients (14 women and 6 men, mean age 43.7±12.6 years,
body mass index <27, 70% married) who met the Rome I criteria for
IBS14 were included. Today the Rome II criteria have replaced the Rome
I criteria for inclusion in most clinical studies on IBS. However, at the
time this study was begun, the Rome II criteria were not available. The
majority of patients had moderate to severe disease severity, assessed by
the Functional Bowel Disorder Severity Index (FBDSI).15 In a previous
study, we reported that patients with moderate to severe FBDSI scores
reported more severe sleep disturbances than did patients with mild
scores.16 No patients had a major psychiatric disorder or a chronic med-
ical problem; none were taking psychiatric drugs, sleeping pills, or mela-
tonin. Subjects were recruited from the roster of IBS patients treated by
2 senior gastroenterologists (ADS, PK) in the gastroenterology clinic of
the Soroka Medical Center. A group of 40 patients was selected from a
list of about 400 names using a table of random numbers. After patients
with exclusion criteria were disqualified, the remaining patients were
contacted and asked if they would like to participate in the study.
Twenty-two patients at the top of the list were contacted, of whom 2
declined. The 20 who agreed to participate comprised the study group.
Based on historical information, there was no indication of sleep-related
medical problems such as obstructive sleep apnea syndrome or periodic
leg movements in these patients. Sixteen of the IBS patients who agreed
to undergo the actigraphy test also completed this aspect of the study.
After completion of the sleep studies, 2 of the 20 IBS patients were
diagnosed with obstructive sleep apnea syndrome and were referred for
further evaluation. In order to not confound the results of the study, these
2 patients were excluded, and all results are based on analysis of the final
IBS group, consisting of 18 patients (13 women and 5 men, age
43.1±12.6, married 67%), 14 of whom completed the actigraph test.
The comparison group (11 women and 9 men, age 43.4±10.0 ?years,
85% married) was selected using a table of random numbers from a list
of 50 patients who were matched by age, body mass index, and sex to
the IBS patients and who had undergone PSG studies over the previous
6 months for suspected obstructive sleep apnea syndrome and were diag-
nosed as mild benign snorers with a respiratory disturbance index below
7 events per hour. None had a chronic disease or IBS. Eleven who agreed
to undergo the actigraphy test also completed this prospective aspect of
the study.
The Institutional Review Committee of the Soroka Medical Center
(Helsinki Committee) approved the protocol, and signed informed con-
sent was obtained from all participants in both groups.
Questionnaires
General Demographic Data and Medical History
Sociodemographic data and data relating to past and current medical
history were obtained from all participants.
Gastrointestinal Symptoms
All participants completed a self-administered questionnaire, which
included standardized questions for diagnosis of IBS in accordance with
the Rome I criteria,14 and a visual analogue scale of abdominal pain.
General Health-Related Questionnaires
All participants completed questionnaires regarding general well
being, healthcare use (physician visits, hospitalizations, operations),
psychological distress (revised Symptoms Checklist 90 [SCL-90R], with
a modification to 87 questions, omitting 3 sleep-related items),17 an anx-
iety state index,18 the disease-specific quality of life IBS-QOL,2and
Antonovski’s Sense of Coherence.19,20
The Hebrew versions of the questionnaires were validated by a
method developed and published by one of the investigators.21
Baseline anxiety and depression were assessed for the IBS patients
using the anxiety state index and the anxiety and depression subscales of
the SCL-90R (see data analysis below).
The FBDSI was calculated to assess the severity of IBS patients’
bowel complaints.15
Sleep Evaluation
All subjects completed a validated 1-month sleep history question-
naire, including sleep hygiene, sleeping hours, sleeping habits, afternoon
naps, and sleep quality, rating the severity of the symptoms on a scale
from 1 to 5 (5 = the most severe). The Epworth Sleepiness Scale was
used to evaluate daytime sleepiness.11
Polysomnographic Evaluation
All subjects underwent a single-night PSG study in our laboratory as
previously described.22 They reported to the laboratory at 8:30 PM and
were discharged at 7:30 AM the following morning. Subjects were
encouraged to maintain their usual daily routine and to avoid any caf-
feine or alcohol intake on the day of the study. Shift workers did not per-
form the PSG study in the week following shift duty.
Scoring of the PSG
Nocturnal sleep-wake and sleep stages were scored in accordance
with the Rechtschaffen and Kales criteria.23 Data were collected using a
commercially available sleep-monitoring system and streamed through
to an optical disk for later analysis. Signals were analyzed by a comput-
erized system (SensorMedics Inc., 4100, USA), and 2 investigators (BF,
ArT) edited the results. Sleep latency was defined as time from lights out
to the first occurrence of 3 consecutive epochs (90 seconds) of stage 1
sleep or the first epoch (30 seconds) of any other stage of sleep. The
REM sleep latency was defined as the time from sleep onset to the first
epoch of REM sleep. Sleep efficiency was calculated as the ratio of total
sleep time (TST) to time in bed (TIB). The time spent in each sleep stage
was expressed as the percentage of TST. Wake after sleep onset (WASO)
was defined as the percentage of time awake after sleep onset and until
final awakening in the morning. Severe sleep impairment (fragmenta-
tion) was defined for the purposes of this study as an arousal or awak-
ening index greater than 20 events per hour.
Arousals and awakenings were scored according to the American
Sleep Disorders Association task force recommendation.24 The arousal
index and the awakening index were calculated as the number of
arousals or awakenings per hour of sleep. In addition, all arousals and
awakenings were designated as 1) associated with leg movement (jerks),
2) associated with apnea or hypopnea (see below), or 3) spontaneous, if
not associated with either of the above. An awakening or arousal was
designated as associated with leg movement if a jerk signal preceded the
electroencephalogram or on submental electromyography signal.
The number of shifts to lighter sleep stages, as an additional index for
sleep fragmentation, was recorded as the number of shifts from deeper
to lighter non-REM sleep or wakefulness, or from REM sleep to any
other sleep stage or wakefulness, according to methods previously
described.22,25
Obstructive sleep apnea was reported when airflow ceased for more
then 10 seconds but abdominal or thoracic movements continued in a
paradoxical or nonparadoxical manner.
Actigraphy
Fourteen patients with IBS and 11 from the comparison group wore
the actigraph (SomnitorTM, Neurim Pharmaceuticals, Israel), a watch-
size device placed on the subjects’ nondominant wrist. The actigraph
was programmed to run for 4 consecutive nights beginning the night
after the PSG study for the IBS patients and upon receipt of consent for
the comparison group. This discrepancy in timing stems from the
Sleep Fragmentation in Patients with Irritable Bowel Syndrome—Rotem et al
SLEEP, Vol. 26, No. 6, 2003 2
method of selection of the comparison group, as described above. The
actigraph was set to record from 7:00 PM to 10:00 AM the following
morning. Subjects were instructed to put the device on about 30 minutes
before bedtime and to remove it shortly after getting up in the morning.
All subjects were encouraged to maintain a regular schedule of activi-
ties. Two of the investigators (BF, ArT) analyzed and reviewed the data
including the following aspects: TIB, TST, sleep period (total time from
sleep onset to sleep offset including midsleep arousals), sleep onset and
offset time, sleep efficiency (TST/TIB multiplied by 100), sleep latency,
WASO, movement index (number of zero crossings/TIB multiplied by
100), fragmental index (percentage of number of quiet episodes that are
shorter than 1 minute from the total quiet episodes), and awakenings
index (number of awakenings/TST). For each subject, data were ana-
lyzed and mean values calculated separately for each of the 4 nights.
Thus, mean data were used for all participants.
Data Analysis
To assess baseline anxiety, depression, or both anxiety and depression
among the IBS patients, we converted the raw scores for each of the 3
scales (anxiety state and the anxiety and depression subscales of SCL-
90R) to t-scores so that the mean was 50 and 1 SD was 10. Assuming
that 2 SDs would be a logical cutoff for clinical abnormality, we catego-
rized high anxiety/depression to be 2 SD or above for each scale. Since
there was only 1 patient in the IBS group who met this definition of high
anxiety and depression, we “lowered” the cut-off point by using (a) 1 SD
and (b) the median. Only 1 additional patient met the 1-SD criteria for
high anxiety/depression, but when the median cut-off was used to dis-
tinguish between low and high anxiety/depression, there were 6 patients
with scores above the median on all 3 scales, 6 patients with scores
above the median on at least 1 scale, and 6 IBS patients who scored
below the median on all 3 scales. The latter 6 patients were defined as
baseline low anxiety/low depression for further analyses. We then com-
pared these 6 low anxiety/low depression IBS patients with the other 12
IBS patients for sleep function and with the comparison group. If anxi-
ety, depression, or both were the reason for the differences in sleep pat-
terns between the study groups, rather than IBS per se, these compar-
isons might introduce a conservative bias to the study, making it more
difficult to prove the study hypothesis.
All data were tested for normal distribution (Kolmagorov-Smirnov
test) and presented as mean ± SD. Data were compared using χ2(Fisher
exact test), correlation analysis (Pearson’s correlation coefficient) or 2-
tailed t-tests for nonpaired groups, as appropriate. The frequency analy-
sis of consecutive epochs as well as nonparametric score data were ana-
lyzed with the Mann–Whitney U-test. The null hypothesis was rejected
at the 5% level.
RESULTS
There were no significant differences between the study groups in
mean age, sex, education, ethnic origin, or family status. Thirteen of the
18 participants in the IBS group and 11 of 20 in the comparison group
were women (P=0.27). The gender composition of the IBS group was
similar to the gender distribution in most epidemiologic studies in west-
ern countries.
The IBS patients’ symptom severity, symptom characteristics, and
quality of life were similar to other IBS groups studied by us.26 The
mean pain score (visual-analog scale) was 37.3±29.6 (0=no pain,
100=severe pain); the mean Global Severity Score (SCL-90-R using 87
items) was 0.8±0.6; the mean FBDSI (mild=1-36), moderate=37-110,
severe=110) was 110.4±111.9, and the mean IBS-QOL score was
72.6±22.2 (0=worst, 100=best). A negative linear correlation was
observed between the FBDSI (analyzed as a continuous variable) and
IBS-QOL (R=–0.57, P<0.01).
Sleep Pattern
Based on the sleep history questionnaire, IBS patients reported more
difficulty falling asleep than did the comparison group (2.9±0.9 vs
2.2±1.0; P=0.06). Significantly more sleep movements were observed
by spouses of IBS patients than by spouses of comparison-group patients
(4.2±3.0 vs 2.1±2.9; P=0.04), and parasomnia complaints, such as talk-
ing during sleep, were significantly more frequent in the IBS group
(3.9±4.1 vs 0.8±2.2; P=0.02). The Epworth Sleepiness Scale revealed a
significantly higher daytime sleepiness score of 9.0±4.8 in the IBS group
compared to 6.4±4.8 in the comparison group (P=0.01).
Polysomnography
Sleep Pattern
Table 1 summarizes the PSG findings. Both groups spent approxi-
mately 6.5 hours in bed. The TST was significantly shorter in the IBS
group by 33 minutes (P<0.05), and their sleep efficiency was reduced by
12% (P<0.0001). The cumulative percentage of stage 2 sleep was longer
in the IBS group (P<0.01), while slow wave sleep (SWS) was consider-
ably shorter in this group (P=0.006). The REM duration and latency to
REM were similar in both groups.
Sleep Fragmentation
The arousal and awakening index was more than 2-fold greater in the
IBS group (Figure 1). The calculated arousals/awakening ratio was
approximately 10:1 for each of the groups. Both increased arousals
Sleep Fragmentation in Patients with Irritable Bowel Syndrome—Rotem et al
SLEEP, Vol. 26, No. 6, 2003 3
Table 1—Sleep and respiratory patterns, by polysomnography
Parameters Comparison group IBS group P
(N, 20) (N, 18)
Sleep pattern
Time in bed (min) 388.8±26.0 397.9±57.6 0.6
Total sleep time (min) 340.0±29.1 309.6±68.1 0.05
Sleep efficiency (%) 88.1± 75.9± 0.0001
Latency to sleep (min) 28.5±23.9 28.3±27.1 0.09
Stage 1 (%) 2.9±0.5 7.3±7.8 0.02
Stage 2 (%) 60.1±16.8 72.2±6.6 0.01
SWS (%) 19.3±12.9 4.5±7.3 0.006
REM (%) 17.9±5.2 14.6±5.6 0.06
Respiratory pattern
RDI (events/hr) 1.4±0.9 2.8±2.6 0.27
DI (events/hr) 0.2±0.5 0.4±1.8 0.46
Wake SaO2 (%) 97.4±2.1 97.1±1.1 0.25
Nadir SaO2 (%) 94.0±3.3 92.3±2.8 0.12
Data are mean±SD. IBS, irritable bowel syndrome; SWS, slow wave sleep (stages 3+4);
REM, rapid eye movement; SaO2,oxygen saturation; DI, desaturation index; RDI, respira-
tory disturbance index
Figure 1—Increased sleep fragmentation in patients with irritable bowel syndrome (IBS)
compared to comparison group: arousal (Ar) and awakening (Aw) index.
(events < 15 seconds) and increased awakenings contributed indepen-
dently to this result. The arousal index was 29.4±9.6 events per hour in
the IBS group compared to 13.1±4.3 events per hour in the control group
(P<0.001). The awakening index (events > 15 seconds) was 3.1±1.2 and
1.7±0.9 events per hour in the IBS and comparison group, respectively
(P<0.001). The IBS patients had close to 30% more shifts to lighter sleep
stages (P<0.01) (Figure 2), reflecting a lighter sleep pattern than the
comparison group. Finally, WASO was significantly longer in the IBS
group (Figure3).
Respiratory Pattern and Legs Movements
We found no evidence of clinically significant sleep-disordered
breathing in the IBS patients and the comparison group, as a group; the
observed respiratory disturbance index was below 10 events per hour
(the minimal criterion for clinically significant obstructive sleep
apnea),27 and there was no indication of oxygen desaturation events or
nadir in either group (Table 1).
Periodic leg movements were observed in 2 IBS patients. In 1, the
movements were benign (6 events/h), and in the other mild (14
events/h). In both cases, the mean number of arousals induced by the leg
movements was only 30% of the total amount observed. In neither of
these 2 cases was obstructive sleep apnea syndrome diagnosed.
Association Between IBS Severity and Sleep Function
The FBDSI was significantly associated with WASO and sleep effi-
ciency (R=0.49, P<0.04 and R=–0.54, P=0.02, respectively) so that
patients with more severe IBS had more WASO episodes and lower
sleep efficiency. Increased sleep fragmentation impaired quality of life
in IBS patients. Sleep efficiency was linearly correlated with IBS-QOL
(R=0.62, P=0.008) and global severity (R=–0.46, P<0.05), so that
patients with better quality of life had greater sleep efficiency, while
those with higher global severity scores had a more-impaired sleep effi-
ciency.
Association Between Sex and Sleep Function
The differences in PSG parameters between the study groups were
still found when data from men and women were analyzed separately.
The arousal and awakening index was 30.0±10.2 for women with IBS
compared to 15.9±5.4 for women in the comparison group (P<0.001).
Similarly, the arousal and awakening index was 27.0±9.6 for men with
IBS compared to 11.3±3.6 for men in the comparison group (P<0.005).
Association Between Baseline Anxiety/Depression and Sleep Function Among
IBS Patients Only
There were no differences in any PSG or actigraphy parameters
between IBS patients with high or low baseline anxiety/depression using
the median cut-off point.
Comparison of Sleep Function Between Low Anxiety/Depression IBS Patients
and the Comparison Group
To further control for the potential confounding effect of baseline anx-
iety, depression, or both anxiety and depression, we compared the sub-
group of 6 IBS patients who were below the median cut-off point for all
3 scales of anxiety and depression with the entire comparison group. The
results are shown in Table 2. The pattern of significant differences
between the groups observed was similar to that found when the full
study groups were compared.
Actigraphy
Actigraphy revealed a significant, 2-fold difference between the study
groups in sleep fragmentation, which was significantly greater (P<0.01)
in the IBS group (Table 3).
DISCUSSION
In this study, we characterized the sleep pattern and quality of 18 IBS
patients, all naïve to polysomnographic and actigraphic examinations
and compared them to a matched comparison group. The results support
the hypothesis that IBS patients suffer from a considerable degree of
sleep fragmentation, including an elevated arousal index, more shallow
sleep, and prolonged awakening during sleep. It is generally acknowl-
edged that sleep disturbances can lead to impairment of daytime func-
tioning and daytime sleepiness. Although in the present study we did not
directly address this issue, symptoms indicative of IBS severity, such as
pain and FBDSI, correlated significantly with sleep fragmentation. The
actigraphy results support the PSG results in respect to the significant
Sleep Fragmentation in Patients with Irritable Bowel Syndrome—Rotem et al
SLEEP, Vol. 26, No. 6, 2003 4
Table 2—Polysomnographic parameters between the comparison
group and patients with IBS with all 3 baseline anxiety/depression
scores below the median (low anxiety/depression).
Parameters Comparison group IBS group P
(N, 20) (N, 6)
Sleep pattern
Time in Bed (min) 388.8±26.0 428.8±30.3 0.009
Total sleep time (min) 340.0±29.1 351.8±52.1 0.65
Sleep efficiency (%) 88.1±6.1 81.7±8.5 0.04
Stage 1 (%) 2.8±0.5 5.1±6.6 0.22
Stage 2 (%) 60.1±16.8 71.5±87.5 0.14
SWS (%) 19.3±12.9 7.2±7.1 0.18
REM (%) 19.7±5.2 16.2±5.0 0.43
Downward shift (events) 13.1±4.4 20.0±3.9 0.002
Awakenings & arousals (index) 13.8±5.4 22.8±7.2 0.002
Data are mean ± SD. IBS, irritable bowel syndrome; min, minutes; SWS, slow wave sleep
(stages 3+4); REM, rapid eye movement
Figure 2—Increased sleep fragmentation in patients with irritable bowel syndrome (IBS)
compared to comparison group: downward shifts from deeper to lighter sleep stages.
Table 3—Actigraphy results
Parameter Comparison group IBS group P
(N, 11) (N, 14)
Sleep variables
Sleep Period (min) 437.4±241.2 388.4±91.5 0.40
TST (min) 358.6±81.2 349.8±97.3 0.90
Sleep Latency (min) 23.8±10.5 52.8±58.4 0.09
Sleep Efficiency (%) 84.8±9.1 73.4±19.9 0.06
WASO (%) 24.0±11.1 38.6±22.9 0.09
SFI (events/hr) 20.8±5.2 38.1±20.1 0.01
AwI (events/hr) 5.1±1.9 7.6±4.8 0.17
Data are mean ± SD. IBS, irritable bowel syndrome; min, minutesTST, total sleep time;
WASO, wake after sleep onset; SFI, sleep fragmentation index; AwI, awakening index
degree of sleep fragmentation.
Earlier studies reported an early onset of REM sleep and prolonged
REM period among IBS patients.5,6 We found no evidence to support
these findings. Earlier studies7also reported that IBS patients have a
longer latency to REM. The latency to REM and its duration were simi-
lar in our study groups but were longer than expected.
The sleep of IBS patients was lighter than the sleep of the comparison
group. This was indicated by a significant increase in cumulative as well
as continuous stage 2 sleep accompanied by a reduction of the SWS
stage, which was more than 50% lower in the IBS group. In contrast,
earlier reports found longer durations of SWS than we did, but with no
differences between patient and control groups.8,28 The differences
between our findings and previous reports may be related to age, since
the mean age of our patients was 10 years older.29 However, analysis of
the results within the patient group by age subset (= 44 years and > 44
years) revealed no difference in the percentage of SWS, the awakening
and arousal index, WASO (all by PSG), or the fragmentation index by
actigraphy.
The patients with IBS had more arousals and awakenings associated
with frequent shifts to lighter sleep stages. These arousals were of short
duration, and the patients were not aware of their existence the follow-
ing day. The arousal and awakening index is an important parameter of
sleep fragmentation. We found an awakening and arousal index of 30±11
events per hour in the IBS patients, more than twice that of the compar-
ison group. Eighty-four percent of the IBS patients had an awakening
and arousal index above 20 events per hour, compared with 15% in the
control group. In adults, experimentally induced arousals at a rate of 20
events per hour lead to impairment of daytime alertness.30,31 This strik-
ing difference between the groups cannot be explained, in our opinion,
solely by the possibility that IBS patients have a higher level of baseline
anxiety, depression, or anxiety and depression. We base this statement on
the finding that there were no significant PSG differences between IBS
patients with and without heightened baseline anxiety and depression. In
addition, the difference between the IBS patients and the comparison
group held true even when the IBS group included only those 6 patients
who were below the median scores for the 3 baseline scales of anxiety
and depression. However, it should be noted that this statement is based
on small patient numbers, and this aspect of the study should be rein-
forced by further studies. We used the accepted guidelines24 for scoring
arousals and awakenings. These results are not consistent with findings
in previous studies8,28 that used similar protocols. The amount of sleep
fragmentation noted in the IBS patients in this study can have a signifi-
cant impact on daytime functioning. In a previous study of patients with
juvenile rheumatoid arthritis, we noted that an arousal-awakening index
of 28 events per hour led to an objective elevation of daytime sleepiness,
as indicated by Multiple Sleep Latency Tests and reports of afternoon
naps.22 In light of these reports, we expected to find an indication of day-
time sleepiness in IBS patients and, indeed, their Epworth Sleepiness
Scale score was elevated.11 However, further studies, particularly using
the Multiple Sleep Latency Test, are needed to support this subjective
evidence.
Poor sleep function may lead not only to daytime sleepiness,32 but
also to impairment of daily activities and mood and reduction in quality
of life.33 Previous studies, using questionnaires, have shown that self-
reported poor sleep quality was associated with exacerbation of IBS
symptoms.7,9,10 In the current study, the reduction of IBS-QOL and
FBDSI severity were related to impairment of WASO, which is a gener-
al indicator for sleep fragmentation.
Wrist actigraphy is used as a supplement to PSG to evaluate patients’
levels of activity and to provide indirect evidence of sleep functioning in
the setting of the patient’s usual schedule.12 The total TIB and the TST
were statistically similar between the groups, but the sleep fragmentation
index was higher in the IBS group. Thus, the actigraphy findings support
the PSG data in respect to sleep fragmentation in IBS patients.
There are several potential methodologic problems that may limit the
results of the present study. The first is the selection of controls. The
comparison group was actually a historical group, which was not recruit-
ed prospectively and for whom we did not evaluate the presence of psy-
chological or psychiatric disorders. In future studies, this limitation
should be addressed. The participants in this group were screened for
IBS and medications that could affect mood or sleep, and none had IBS
or were taking medications of this type. The amount of arousals increas-
es with age.34 The arousal and awakening index of 14±4.5 events per
hour found in our comparison group is similar to that of normal individ-
uals in the same age group. It is also similar to various comparison
groups previously investigated in our laboratory.22,35,36 According to
Mathur and Douglas34 healthy individuals in the age range investigated
here should have an arousal index of 14 to 15 events per hour, which is
similar to that found in our comparison group. The comparison group
used here did not exhibit symptoms of daytime sleepiness. The Epworth
Sleepiness Scale score in this group was 6.4±4.8, which is within the
range of normal controls or persons with primary snoring.11 Therefore,
we believe that they represent a valid comparison group for this study. If
anything, this choice of a comparison group introduces a potential neg-
ative bias to the study, and it is reasonable to assume that if the compar-
ison had been to totally healthy controls, the differences might have been
even more significant.
Another possible limitation in this study is the “first-night” effect on
sleep architecture, in which sleep disturbances are observed during the
first night in a PSG laboratory. However, we do not believe that this seri-
ously confounded the study results because the comparison group was
tested under similar circumstances. It should be noted that all previous-
ly published reports on sleep function in IBS were also based on single-
night PSG studies.
Finally, sleep apnea, which has been considered to be a potential con-
founder in studies of this type, cannot be considered a problem in the
present study because there were no differences in respiratory variables
between the groups, and obstructive sleep apnea was not found in the
participants, so the number of arousals associated with apnea is negligi-
ble.
In conclusion, we found objective PSG and actigraphy evidence of
abnormal sleep in patients with IBS. The sleep disruption was due to fre-
quent arousals and awakenings, frequent sleep-stage shifts, and waking
periods during sleep. In addition, there was considerable reduction of
SWS. The sleep fragmentation may be the cause of daytime sleepiness,
as reflected in the higher scores on the Epworth Sleepiness Scale in the
IBS group. The impaired sleep function could also explain the impair-
Sleep Fragmentation in Patients with Irritable Bowel Syndrome—Rotem et al
SLEEP, Vol. 26, No. 6, 2003 5
Figure 3—Increased sleep fragmentation in patients with irritable bowel syndrome (IBS)
compared to comparison group: wake after sleep onset (WASO).
ment in quality of life and associated symptoms among IBS patients. In
order to overcome some of the limitations of the present study, we rec-
ommend conducting similar studies with consecutive-night PSG studies,
including an objective evaluation of daytime sleepiness by the Multiple
Sleep Latency Test, that will help to verify the association between day-
time symptoms and objective PSG results.
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- CitationsCitations54
- ReferencesReferences38
- One of the important risk factors of IBS among medical students is sleep disturbance. IBS patients experience impairment in sleep quality, reduction in slow-wave sleep activity, and significant sleep fragmentation [37]. A study among medical students and interns in Saudi Arabia showed that students who slept less than eight hours per day had a higher prevalence of IBS [17].
[Show abstract] [Hide abstract] ABSTRACT: Irritable bowel syndrome (IBS) has been identified as one of the more highly prevalent and costly gastrointestinal disorders. Despite its uncertain etiology, risk factors, such as stress and academic load, are well correlated with the prevalence of the disease. Being in one of the most stressful and challenging environments, medical students are predisposed to have high rates of IBS. The socioeconomic burden of the disease on its sufferers is devastating as their quality of life is reduced, mandating additional health care precautions. The aim of this article, therefore, is to review the current literature about IBS among medical students, its prevalence, associated risk factors, and diagnostic criteria. Additionally, different solutions and management options are recommended to control the disease.- In the study, we found little difference between UARS patients and healthy controls in objective sleep architecture or fragmentation, despite clear differences in subjective assessments of sleep quality and daytime sleepiness/fatigue [8]. Bringing together previous findings regarding alpha frequency intrusion into sleep and sleep stage instability among UARS234 and IBS [6,9] patients, we suggested that rather than being considered a disorder of increased sleep fragmentation, UARS should be considered a disorder of chronic stress [10]. By ''chronic stress'', we mean ''a condition in which the hypothalamic–pituitary–adrenal axis and the sympathetic nervous system (SNS) are chronically activated .''
[Show abstract] [Hide abstract] ABSTRACT: Objectives We tested the hypothesis that the symptoms of upper airway resistance syndrome (UARS) are manifestations of chronic stress. To accomplish this we utilized the score on a self-report questionnaire for somatic arousal (a component of stress) to compare somatic arousal between UARS patients and healthy controls and, among all participants, to correlate the level of somatic arousal with the severity of UARS symptoms. Methods We administered the Mood and Anxiety Symptom Questionnaire anxious arousal subscale (MASQaas; a 17-item questionnaire with increasing levels of arousal scored 17-85) to 12 UARS patients and 12 healthy controls and compared scores between groups. For all participants, we correlated the MASQaas scores with scores for the Epworth Sleepiness Scale (ESS), Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-fatigue) scale, Pittsburgh Sleep Quality Index (PSQI), SF-36 Health Survey and Perceived Deficits Questionnaire (PDQ; assessing cognitive function). Results Compared to healthy controls, UARS patients demonstrated increased somatic arousal (MASQaas scores of 18 ± 2 and 28 ± 7 respectively; p < 0.0001). For all participants, the MASQaas scores correlated significantly with scores of the ESS (r = 0.64; p = 0.0008), the FACIT-fatigue scale (r = -0.89; p < 0.0001), the PSQI (r = 0.70; p = 0.0002), SF-36 Physical component (r = -0.78; p < 0.0001), SF-36 Mental component (r = -0.74; p < 0.0001) and the PDQ (r = 0.89; p < 0.0001). Conclusions Our findings suggest that UARS patients have increased levels of the stress component, somatic arousal, proportionate to the severity of their symptoms.- Prominent sleep disorders commonly occur in patients with IBS. Patients with IBS have impaired sleep quality, reduced slow-wave sleep activity, and significant sleep fragmentation [283], but increased proportion of REM sleep [284]. The overall insomnia rate in IBS patients was found to be about 26.0 % compared with the control mean score of total Pittsburgh Sleep Quality Index (PSQI) of 5.83 [285] .
[Show abstract] [Hide abstract] ABSTRACT: The irritable bowel syndrome (IBS) is a common chronic functional gastrointestinal disorder world wide that lasts for decades. The human gut harbors a diverse population of microbial organisms which is symbiotic and important for well being. However, studies on conventional, germ-free, and obese animals have shown that alteration in normal commensal gut microbiota and an increase in pathogenic microbiota-termed "dysbiosis", impact gut function, homeostasis, and health. Diarrhea, constipation, visceral hypersensitivity, and abdominal pain arise in IBS from the gut-induced dysfunctional metabolic, immune, and neuro-immune communication. Dysbiosis in IBS is associated with gut inflammation. Gut-related inflammation is pivotal in promoting endotoxemia, systemic inflammation, and neuroinflammation. A significant proportion of IBS patients chronically consume alcohol, non-steroidal anti-inflammatories, and fatty diet; they may also suffer from co-morbid respiratory, neuromuscular, psychological, sleep, and neurological disorders. The above pathophysiological substrate is underpinned by dysbiosis, and dysfunctional bidirectional "Gut-Brain Axis" pathways. Pathogenic gut microbiota-related systemic inflammation (due to increased lipopolysaccharide and pro-inflammatory cytokines, and barrier dysfunction), may trigger neuroinflammation enhancing dysfunctional brain regions including hippocampus and cerebellum. These as well as dysfunctional vago-vagal gut-brain axis may promote cognitive impairment. Indeed, inflammation is characteristic of a broad spectrum of neurodegenerative diseases that manifest demntia. It is argued that an awareness of pathophysiological impact of IBS and implementation of appropriate therapeutic measures may prevent cognitive impairment and minimize vulnerability to dementia.- The Epworth Sleepiness Scale (ESS) was used to evaluate daytime sleepiness [39]. Overnight PSG was performed according to previously described methods [3,40]. Subjects reported to the laboratory at 20:30 and were discharged at 06:00 the following morning.
[Show abstract] [Hide abstract] ABSTRACT: Although awareness of sleep disorders is increasing, limited information is available on whole night detection of snoring. Our study aimed to develop and validate a robust, high performance, and sensitive whole-night snore detector based on non-contact technology. Sounds during polysomnography (PSG) were recorded using a directional condenser microphone placed 1 m above the bed. An AdaBoost classifier was trained and validated on manually labeled snoring and non-snoring acoustic events. Sixty-seven subjects (age 52.5±13.5 years, BMI 30.8±4.7 kg/m(2), m/f 40/27) referred for PSG for obstructive sleep apnea diagnoses were prospectively and consecutively recruited. Twenty-five subjects were used for the design study; the validation study was blindly performed on the remaining forty-two subjects. To train the proposed sound detector, >76,600 acoustic episodes collected in the design study were manually classified by three scorers into snore and non-snore episodes (e.g., bedding noise, coughing, environmental). A feature selection process was applied to select the most discriminative features extracted from time and spectral domains. The average snore/non-snore detection rate (accuracy) for the design group was 98.4% based on a ten-fold cross-validation technique. When tested on the validation group, the average detection rate was 98.2% with sensitivity of 98.0% (snore as a snore) and specificity of 98.3% (noise as noise). Audio-based features extracted from time and spectral domains can accurately discriminate between snore and non-snore acoustic events. This audio analysis approach enables detection and analysis of snoring sounds from a full night in order to produce quantified measures for objective follow-up of patients.- Patients with IBS frequently report co-morbid pain-related conditions and daily fatigue as well as the interference of symptoms, quality of life and everyday functioning (Lackner et al., 2006). Among the most commonly reported symptoms accompanying IBS is poor sleep, including difficulty getting asleep, frequent awakenings during sleep, feeling un-refreshed in the morning, and poor overall sleep quality (Bellini et al., 2011; Heitkemper et al., 2005)Heitkemper et al., 2005) and decreased slow wave sleep (Rotem et al., 2003). Elsenbruch with Orr (Elsenbruch, Thompson, Hamish, Exton, & Orr, 2002) reported that while self-report of disturbed sleep was greater in a group with IBS there were no differences in PSG variables (REM and non-REM sleep stages) when compared to a group of healthy controls.
[Show abstract] [Hide abstract] ABSTRACT: This article provides an update and overview of a nursing research program focused on understanding the pathophysiology and management of irritable bowel syndrome (IBS). This review includes English language papers from the United States, Europe, and Asia (e.g., South Korea) from 1999 to 2013. We addressed IBS as a health problem, emerging etiologies, diagnostic and treatment approaches and the importance of a biopsychosocial model. IBS is a chronic, functional gastrointestinal disorder characterized by recurrent episodes of abdominal pain and alterations in bowel habit (diarrhea, constipation, mixed). It is a condition for which adults, particularly women ages 20-45, seek health care services in both the United States and South Korea. Clinically, nurses play key roles in symptom prevention and management including designing and implementing approaches to enhance the patients' self-management strategies. Multiple mechanisms are believed to participate in the development and maintenance of IBS symptoms including autonomic nervous system dysregulation, intestinal inflammation, intestinal dysbiosis, dietary intolerances, alterations in emotion regulation, heightened visceral pain sensitivity, hypothalamic-pituitary-adrenal dysregulation, and dysmotility. Because IBS tends to occur in families, genetic factors may also contribute to the pathophysiology. Patients with IBS often report a number of co-morbid disorders and/or symptoms including poor sleep. The key to planning effective management strategies is to understand the heterogeneity of this disorder. Interventions for IBS include non-pharmacological strategies such as cognitive behavior therapy, relaxation strategies, and exclusion diets.- between sleep-disordered breathing and other idiopathic pain conditions, including fibromyalgia (Moldofsky et al., 1975), irritable bowel syndrome (Rotem et al., 2003), and headache (Rains and Poceta, 2012). One mechanism by which SDB may contribute to pain over time is through the effect of central sensitization and pain amplification in decreasing function in pain inhibitory systems (Smith et al., 2007), for example, via baroreceptor pathways.
[Show abstract] [Hide abstract] ABSTRACT: The authors tested the hypothesis that obstructive sleep apnea (OSA) signs/symptoms are associated with the occurrence of temporomandibular disorder (TMD), using the OPPERA prospective cohort study of adults aged 18 to 44 years at enrollment (n = 2,604) and the OPPERA case-control study of chronic TMD (n = 1,716). In both the OPPERA cohort and case-control studies, TMD was examiner determined according to established research diagnostic criteria. People were considered to have high likelihood of OSA if they reported a history of sleep apnea or ≥ 2 hallmarks of OSA: loud snoring, daytime sleepiness, witnessed apnea, and hypertension. Cox proportional hazards regression estimated hazard ratios (HRs) and 95% confidence limits (CL) for first-onset TMD. Logistic regression estimated odds ratios (OR) and 95% CL for chronic TMD. In the cohort, 248 individuals developed first-onset TMD during the median 2.8-year follow-up. High likelihood of OSA was associated with greater incidence of first-onset TMD (adjusted HR = 1.73; 95% CL, 1.14, 2.62). In the case-control study, high likelihood of OSA was associated with higher odds of chronic TMD (adjusted OR = 3.63; 95% CL, 2.03, 6.52). Both studies supported a significant association of OSA symptoms and TMD, with prospective cohort evidence finding that OSA symptoms preceded first-onset TMD.
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