Sleep and Cardiovascular Health in Adolescence
Condition: Insomnia Type; Sleep Disorder
MeSH terms: Sleep Wake Disorders
Study type: Interventional

Summary: 
      Insomnia is a prevalent and under-recognized disorder in adolescence, particularly in girls,
      with long-term repercussions for mental and physical health. This study assesses
      manifestation of autonomic hyperarousal and vulnerability to insomnia using a sample of male
      and female adolescents with and without Diagnostic and Statistical Manual (DSM-5) Insomnia
      Disorder. Outcomes from this study have the potential to inform prevention and treatment
      interventions for insomnia that can be implemented at a young age before chronic negative
      sequelae of this common disorder manifest.
    

Detailed description: 
      Insomnia is highly prevalent in adolescence, particularly in post-pubertal girls and tends to
      persist over time. Insomnia is considered a hyperarousal disorder, in which abnormally
      elevated levels of cognitive and physiological activation, particularly evident at bed-time,
      prevent individuals from falling asleep and having a restorative night's sleep. Hyperarousal
      is a major pathophysiological mechanism linking insomnia with poor mental and physical
      health, including cardiovascular (CV) disease. The investigators and others have shown
      evidence of autonomic nervous system (ANS) dysfunction such as hyperactivation of the
      sympathetic branch of the ANS - a major etiological factor in CV disease - in young and
      midlife adults, both before and during sleep. It is unknown if ANS hyperarousal is evident in
      adolescents with insomnia.

      The biological basis for an emerging sex difference in insomnia prevalence in adolescence is
      unknown. The investigators' pilot data reveal intriguing evidence of sex-differences in basic
      and stress-dependent ANS modulation during sleep in adolescents with girls showing a greater
      ANS response to stress. These data suggest the existence of a predisposing and
      stress-dependent ANS vulnerability in female adolescents, a potential pathway to develop
      insomnia. This study takes a novel approach to investigating the manifestation of
      physiological ANS and CV hyperarousal in adolescents with insomnia by experimentally
      manipulating the pre-sleep arousal state via stress-induced ANS up-regulation and
      relaxation-driven ANS down-regulation. In addition, the study focuses on sex differences in
      ANS and CV responses to pre-sleep ANS manipulation, potentially addressing the question of
      why female sex is a major risk factor for insomnia.

      The investigators aim to test 110 male and female high-school students (16-20y) with and
      without DSM-5 Insomnia Disorder, during a regular in-lab polysomnographic night (baseline)
      and under experimental pre-sleep stress (psychosocial stressor) and pre-sleep relaxation
      (Virtual reality ANS bio-feedback) intervention nights, using state-of-the-art, noninvasive,
      beat-to-beat ANS and CV measures, including blood pressure, to assess nocturnal ANS and CV
      function in adolescents with insomnia (Aim 1); the impact of pre-sleep ANS arousal levels on
      nocturnal ANS and CV function, and sleep in adolescents with and without insomnia,
      considering possible sex differences (Aim 2), and the extent to which nocturnal ANS and CV
      function mediate the effect of pre-sleep arousal levels on objective and perceived sleep
      quality (Aim 3).

      This study has the potential to elucidate pathophysiological ANS hyperarousal underlying
      Insomnia Disorder in adolescence, including potential reasons for the vulnerability to
      insomnia in girls, leading to better recognition and potentially new treatment strategies of
      this disorder targeted at the state of ANS hyperarousal in the pre-sleep period.
    

Intervention name(s): No pre-sleep arousal manipulation; pre-sleep arousal down-regulation; pre-sleep arousal up-regulation
Intervention type(s): Other; Other; Other
Intervention description(s): As with the pre-sleep arousal up- and down-regulation nights, the participant will sleep in comfortable sound-proof and temperature-controlled bedroom and will go to bed and wake up at his/her self-reported usual school-week times. On this night, pre-sleep activities include watching television or reading a book.; On the "low pre-sleep arousal night", about 30 min before lights-out, a 20 min session of relaxation-driven Virtual Reality (VR) + slow breathing will be conducted. Adolescents will be instructed to perform slow diaphragmatic breathing and to let the VR immersion guide them through this relaxation process.; On the "high pre-sleep arousal" night, an anticipatory stress procedure from the Trier Social Stress Test (TSST) will be used to elicit stress-induced ANS activation in the pre-sleep period. About 30 min before lights-out participants will be told that the following morning they will need to prepare and give a 5-min speech in front of a panel of assessors who will judge their performance and ask questions. Participants will be shown the testing room (set up with chairs, video camera, microphone).
Other intervention name(s): Baseline; pre-sleep relaxation; pre-sleep stress
Allocation: Randomized
Intervention model: Crossover Assignment
Intervention model description: The experimental paradigm will consist of three in-lab counterbalanced non-consecutive (≥2 days in-between) polysomnography (PSG) nights in which we will modulate the level of pre-sleep psychophysiological arousal in a group of insomnia and non-insomnia adolescents.
no pre-sleep arousal manipulation night;
pre-sleep arousal down-regulation night (pre-sleep relaxation-driven Virtual reality ANS downregulation);
pre-sleep arousal up-regulation night (pre-sleep anticipation of stress using the Trier Social StressTest).
Masking: None (Open Label)
Primary purpose: Basic Science
Keywords: Cardiovascular; Blood Pressure; ECG; EEG