Each subject also received instructions about abdominal breathing. During the second session, we analyzed each subject’s sleep diary and conducted their sleep restriction therapy based on information from the analysis. Additionally, the subjects were instructed to continue their sleep diaries. The first was the baseline session, in which we assessed subjects for sleep and psychiatric disorders and taught them about psychophysiological insomnia and sleep hygiene. A psychiatrist (sleep specialist) and a specialized nurse conducted all sessions, individualized for each subject. In the present study, cognitive-behavioral treatment (CBT) consisted of four sessions, one every other week over an eight-week period. This protocol was approved by the Institutional Review Board of the Asan Medical Center. 24 The subjects underwent four non-pharmacological treatment sessions over an 8-week period, after which we repeated the rating scales and HRV test. These rating scales were the Insomnia Severity Index (ISI), 19 the Pittsburg Sleep Quality Scale (PSQI), 20 the Epworth Sleepiness Scale (ESS), 21 the abbreviated version of the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16), 22 the Hospital Anxiety and Depression Scale (HADS), 23 and the Pre-Sleep Arousal Scale (PS-AS). We administered the HRV test and various rating scales to the subjects at baseline. To assess patients for sleep disorders such as RLS, PLMS, and OSAS, we utilized sleep questionnaires and/or reports from the patients and their families. The subjects were asked to complete a sleep diary for a week. All prospective participants underwent a full history and psychiatric examination by a psychiatrist (sleep specialist). 18 The exclusion criteria were 1) current use of sleeping pills, psychotropic agents, antihypertensive or antihyperlipidemic agents, or medication to treat diabetes 2) presence of a concurrent major psychiatric condition, such as major depressive disorder or anxiety disorder and 3) the presence of other, concurrent sleep disorders, such as circadian rhythm sleep disorder, restless legs syndrome (RLS), periodic limb movements during sleep (PLMS) or obstructive sleep apnea syndrome (OSAS). All patients had been newly diagnosed with psychophysiological insomnia according to the diagnostic criteria of the International Classification of Sleep Disorders-2 nd edition. Between May 2009 and November 2010, we recruited subjects from the sleep clinic at the Department of Psychiatry in the Asan Medical Center.
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