Personality features ina sample of psychophysiological insomnia patients

Características de personalidade em uma amostra de pacientes com insônia psicofisiológica

Personality features ina sample of psychophysiological insomnia patients

Características de personalidade em uma amostra de pacientes com insônia psicofisiológica

Luciane Bizari Coin de Carvalho^I; Eliane Aversa Lopes^II; Luciana Silva^II; Marilaine Medeiros de Almeida^II; Tatiana Almeida e Silva^II; Afonso Carlos Neves^III; Lucila Bizari Fernandes do Prado^IV; Gilmar Fernandes do Prado^V

Center for Clinic and Science of Sleep (CCSS), Departments of Neurology and Emergency Medicine, Federal University of São Paulo, São Paulo SP, Brazil. (UNIFESP)

^IPhD, Department of Neurology, Researcher of CCSS, partially supported by FAPESP 00/07513-3

^IIPhD, Department of Emergency Medicine, Researcher of CCSS

^IIIMD, PhD, Department of Neurology, Researcher of CCSS

^IVMD, Department of Neurology, Co-Director of CCSS

^VMD, PhD, Departments of Neurology and Emergency Medicine, Director of CCSS

ABSTRACT

The personality is the way people express themselves inside the environment they live. Sleep, quality or quantity, is a way of this physical and psychological expression of well being. Psychological factors, associated with psychophysiological insomnia (PPI) suggest an exaggerated perception of the difficulties to fall asleep. Worries, anxiety and the fear of not sleeping produce a bad sleep quality or sleep misperception. This study aims to identify personality features associated with PPI throughout Rorschach test (RT).

METHOD: We studied 32 patients with PPI (22 women), between 29 and 75 years old. We excluded patients with other sleeping or psychiatric disorders. We analysed the data from PPI patients submitted to the RT and we compared our results with the standard data.

RESULTS: We noticed a significant increase in global answers and a significant decrease in detailed answers; a trend of a low number of answers; great number of shape and animal answers, especially for women.

CONCLUSION: The features of the PPI patient's personality were daily problems insecure and the incapability to avoid or remove them from their thought, making bedtime a time for worries to appear again and motivate insomnia.

Key words: psychophysiological insomnia, cognitive behavioral therapy, Rorschach test, personality.

RESUMO

Personalidade é a maneira pela qual o indivíduo se expressa dentro do seu mundo. O sono, quantidade ou qualidade, é uma forma de bem-estar físico e psicológico. Fatores associados à insônia psicofisiológica (IP) sugerem uma exagerada percepção da dificuldade para iniciar o sono, Preocupações, ansiedade e medo de não dormir geram uma qualidade ruim de sono ou estado de impercepção do sono. Este estudo tem como objetivo identificar características de personalidade associadas à IP através do teste de Rorschach (TR).

MÉTODO: Estudamos 32 pacientes com IP (22 mulheres), entre 29 e 75 anos. Excluímos pacientes com outros distúrbios do sono ou psiquiátricos. Nós analisamos os dados dos pacientes com IP submetidos ao TR e comparamos nossos achados com valores referenciais da literatura.

RESULTADOS: Observou-se: aumento significante de respostas globais, diminuição significante de respostas de detalhe; tendência a baixo número de respostas; grande quantidade de respostas de forma e de conteúdo animal, especialmente para as mulheres.

CONCLUSÃO: As características de personalidade dos pacientes com IP foram insegurança em relação aos problemas diários e incapacidade para evitá-los ou tirá-los do pensamento, tornando a hora de dormir um período propício para preocupações reaparecerem e motivar a insônia.

Palavras-chave: insônia psicofisiológica, terapia comportamental cognitiva, teste de Rorschach, personalidade.

The personality is the way people express their wishes, affections, perception of physical features, and others, in the environment they live. There are social and moral rules that control people actions and reactions, restricting these expressions or fitting in with acceptable ways and not invading people limits. There are different ways of internal and external perceptions for the persons that have different feelings about themselves and about the physical and social environment. Quality and quantity sleep is the relationship of a physical and psychological feeling expression of people in their environment¹. Psychological factors associated with psychophysiological insomnia (PPI) suggest an exaggerated perception of the difficulties to fall asleep, increasing anxiety when approaching bedtime, a fear of not sleeping, complicated rituals in order to sleep, frustration with the insomnia, worries about daily situations, which has, as a result, bad quality of sleep or even sleep state misperception^1,2. The emotional precipitate insomnia factors change the behaviour about the perception of themselves and the non-comprehension of these factors prevents the person from sleeping. The social factor has got an important part: family pressure, social isolation (not taking part in trips for example), productivity decrease, car accidents, mood disturbances, depression, decrease of sexual wishes, and also the high costs for diagnosis and treatment of insomnia³.

The difference between the subjective perceptions and the objective factors that cause insomnia, difficulties the diagnosis and treatment³. Even people, who think that they sleep well, overestimate the time awakened and underestimate the sleep time over the night. At sleep laboratories, we saw that the people who show PPI sleep better than at home, it happens because they are far from the insomnia conditioned environment. The Cognitive Behavioral Therapy (CBT) for PPI patients is set because it can change habits and values that define sleep as dissatisfaction⁴. When you know the patient's personality, their way of perception and reaction to the environment where they live, it facilitates the diagnosis of the insomnia perpetuates factors, increasing the habit changes^4,5. Some researchers consider insomnia's personality in the treatment of PPI. Rorschach test (RT) is a projective instrument used to evaluate personality and though it can have other applications, it is rich in interpretations and it could be a very good tool to help the CBT⁶.

The primary goal of this study is to describe personality features of PPI patients throughout RT.

METHOD

We studied 32 patients with PPI, diagnosed according to The International Classification of Sleep Disorders⁷, 22 women and 10 men, between 29 and 75 years old (mean age was 43 years for men and 51 years for women), attending to the Center of Clinic and Science of Sleep, Departments of Neurology and Emergency Medicine, Federal University of São Paulo, SP, Brazil. We excluded the patients with other sleep or psychiatric disorders, based upon clinical and psychological approach.

We analysed the data from PPI patients submitted to the RT that consists of 10 inkblot cards with many interpretations. The evaluation considered WHAT (content), WHERE (localization) and HOW (motivation) you can see the answer^8,9. The answers can be localized in the whole picture (global answers) or in a common or rare detail in the card (detail). The answers can be motivated by the shape, color or movement imagined from the card. The most frequent answers in RT are about human and animal content; there can also appear scenes, anatomy, blood or others. We compared our results: a total number of answers, global, details, shapes, color, movement, animal and human answers, with the normal values expected, classically referred to in literature^8,9. We analyzed the data throughout Z test or T test.

RESULTS

Our patients showed: a) a significant increase in global and shape answers (Table 1; p<0,0001); b) a significant decrease in common and rare details answers (p<0,0001); c) a trend for a low number of total answers, and a great number of animal answers (p=0,06). The shape and animal answers showed tendencies to be greater for women (Table 2; p=0,24;p=0,17) and human answers for men (p=0,15).

DISCUSSION

RT allows people to express themselves through images that stimulate projections and fantasies without a control of it. The test interpretation allows the realization of a clear drawing about the patient's personality features and the conflicts that they are facing⁸. The small number of answers observed in our patients is associated to the PPI patient repressed perception. Many global and few detailed answers suggest that emotion (much more than the logical thought) had restricted the patient associative capacity. The large number of shape answers shows that there are emotional difficulties, because they only use the concrete elements of the image, which have the known function to repress emotions. The same way to escape from the emotions is represented by the animal content answers, which is a feature of the stereotyped personality. The patients showed emotional conflicts that are uncontrollable, although the effort to repress them.

Our data, in short, suggests that PPI patients were daily problems insecure and incapable to avoid or to remove them from their thought, making the bedtime a time for worries to appear again and motivate sleep disturbances. Vicent and Walker¹⁰ have studied the perfectionism and chronic insomnia, and observed that their patients are "maladaptive" perfectionistic, in relation to the control, criticism, and insecurity. These personality features were stronger in women, which ratifies the finding in the literature that shows women being more affected by PPI¹¹. It can be associated to the increase number of modern-day women activities, who work at and out of home, and which make them sleep less than necessary and therefore subjects them to anxiety, depression and bad thoughts. Women also showed a trend to have more repressed (shape answers) and stereotyped personality (animal answers).

This initial case study without a control group, allows us to conclude that the PPI personality features were: the association capacity influenced by emotion, the repressed emotion showed by stereotyped and stimulus concrete perception. The women have showed these features, insecurity and incapacity to deal with daily problems. Because we compared our data to standard data referred to in literature, we can not be sure about many of them, so we suggest a future investigation enrolling a control group to match for cultural variables.

Acknowledgement - Mr Warren from Personal Touch Idioms.

Received 4 December 2002, received in final form 26 February 2003

Accepted 14 March 2003

Dr. Gilmar F. Prado - Rua Claudio Rossi 394 - 01547-000 São Paulo SP - Brasil. FAX: [phone]. E-mail: [e-mail]

• 1. Kryger MH, Roth T In Principles and practice of sleep medicine. 2.Ed. Philadelphia: WB Saunders Company, 1994:483-548.
• 2. Vgontzas AN, Kales A. Sleep and its disorders. Annu Rev Med 1999;50:387-400.
• 3. Morin CM. The nature of insomnia and the need to refine our diagnostic criteria. Psychosom Med 2000;62:483-485.
• 4. Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological therapies for late-life insomnia, a randomized controlled trial. JAMA 1999;281:991-999.
• 5. Riedel BW, Lichstein KL. Strategies for evaluating adherence to sleep restriction treatment for insomnia. Behav Res Ther 2001;39:201-212.
• 6. Prado GF, Carvalho LBC, Baptista da Silva A, Lima JGC. EEG and dementia indicators in AIDS patients Rorschach test. Arq Neuropsiquiatr 1994;52:314-319.
• 7. The International Classification of Sleep Disorders. Diagnostic and Coding Manual. Pocket Edition. Produced by Diagnostic Classification Steering Committee of the American Sleep Disorders Association. Kansas: Allen Press Inc., 1991.
• 8. Bohm E. Manual del psicodiagnóstico de Rorschach. Madrid: Ediciones Morata, 1984.
• 9. Augras M (ed). Teste de Rorschach: atlas e dicionário - padrões preliminares para o meio brasileiro. 8.Ed. Rio de Janeiro: Fundação Getúlio Vargas, 1999.
• 10. Vincent NK, Walker JR. Perfeccionism and chronic insomnia. J Psychosom Res 2000;49:349-354.
• 11. Loayza MP, Ponte TS, Carvalho CG, et al. Association between mental health screening by self-report questionnaire and insomnia in medical students. Arq Neuropsiquiatr 2001;59:180-185.

Publication Dates

• Publication in this collection
  16 Sept 2003
• Date of issue
  Sept 2003

History

• Reviewed
  26 Feb 2003
• Received
  04 Dec 2002
• Accepted
  14 Mar 2003