ADVERTISEMENT

Upcoming Website Maintenance Notification

On Sunday October 20th, 2019 from 5:00 am cst to 8:00 am cst there will be approximately 3 hours of scheduled downtime while we make upgrades to our servers. During this time-window the JCSM website will be unavailable. Thank you for your patience.

gears

Issue Navigator

Volume 11 No. 08
Earn CME
Accepted Papers





Book Reviews

Insomniac

Frank M. Ralls, MD1,3; Swala K. Abrams, MD2,4
1Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM; 2Department of Psychiatry, University of New Mexico School of Medicine, Albuquerque, NM; 3University of New Mexico Hospital Sleep Disorders Center, Albuquerque, NM; 4University of New Mexico Psychiatric Center, Albuquerque, NM

Insomniac, by Gayle Greene, provides an interesting perspective and offers support to those with treatment resistant insomnia. It also offers a fresh perspective to readers who are also medical providers. The author defines insomnia in a way that sets the stage for the discussions that follow, as “Insomnia is when you can't get the sleep you need to feel good, for no reason other than that you can't.” By the end of the third chapter, the reader has a very clear understanding of the problems faced by insomniacs.

Insomniac is 503 pages of personal vignettes, reassurance, suggestions, and empathy, as well as criticisms of the inadequacies of the medical community to effectively treat this disabling malady. Dr. Greene summarizes the current understanding of insomnia and its treatment in a way that is easy to read and accessible to the general public. As an experienced Sleep Medicine practitioner, I was pleased to also be challenged to reconsider my own attitudes about treatment resistant insomnia. The author takes the reader into the world of insomniacs who have truly tried everything to treat a condition that has haunted them since childhood. She personalizes the frustrations of ongoing symptoms by emphasizing that patients such as herself have endured every imaginable hardship, followed every prescribed treatment regimen, and symbolically travelled far and wide to consult the wisest sages in the world. Despite this, however, insomnia wins the battle nightly.

In chapter 3,”Blame the Patient,” great difficulties encountered by the insomniac are addressed, such as when providers, addressing a chronic unremitting condition they cannot fix, wish the patient would just “go away” or seek a way to avoid the inevitable difficult conversations. Dr. Greene explains that phrases such as “I've struggled with this my whole life” or “I've done everything, I never sleep!” add to the provider's discomfort and desire to refer to a specialist—a counselor, psychologist, or psychiatrist. The complex, multi-factorial, and deeply entrenched pathology of insomnia is much like that of chronic pain, where patients are passed from one specialist to another, often endlessly in search of an effective modality of treatment.

This author skillfully reiterates and reinforces the fact that for some individuals, insomnia is refractory to all pharmacotherapies, cognitive behavioral therapy (CBT) and other psychotherapies, and all lifestyle modifications. These unfortunates live in complete avoidance of Spielman's 3Ps: Predisposing, Precipitating, and Perpetuating, and yet they just can't sleep. Insomnia gives examples of individuals who have completed hours of CBT, mastered biofeedback, removed the curtains from the bedrooms to allow blinding sunshine to reset the circadian clock, have drank every tea, no matter how sweet, bitter, or disgusting, and have taken melatonin, melatonin plus, and melatonin plus plus plus. They have even thrown out the TV, the dog, and their bed partners, but to no avail.

The author discusses practicing the art of “getting quiet” only to find that silence, solitude, meditation, and focused relaxation only served to allow the pain from her left knee to shatter her tranquility and prompt even more sleeplessness. She notes that her own obsessive ruminations are not quieted by the distraction strategies recommended by the father of sleep medicine (Dr. William C. Dement of Stanford University), such as starting with one hundred and counting backwards by seventeen, playing word games, or engaging in prayer. Insomnia will not be tricked into remission!

Much like sufferers of Smith-Magenis Syndrome, where there is an inverted circadian release of melatonin such that melatonin is released in the morning, the genetic makeup of chronic insomnia sufferers produces a disorder of arousal that prevents normal sleep. Beta waves (wake) as spindles predominate and delta waves are scarce. The retinohypothalamic circadian clock that regulates sleep and wake is dysfunctional in 6% to 10% of the population of chronic insomnia sufferers.

The great discoveries of Paracelsus (the opium tincture laudanum), Fischer and Mering (barbital, initially used to anaesthetize dogs), and Leo Sternbach (chlordiazepoxide) have added little to the treatment of insomnia. In Insomniac, Dr. Greene investigates the development of common modern drugs, including haloperidol, zolpidem, and trazodone. Also reviewed is the off-label use of sodium oxybate for insomnia.

Insomnia reassures insomniacs that they are not alone in their plight to find a cure and Dr. Greene does a nice job of advising and advocating fellow sufferers. Quotes from peers are sprinkled throughout the book, further highlighting their plight. The book is well indexed, and following the final chapter, the author provides citations and short notes about various quotes, as well as the website www.SleepStarved.org, which expands on the notes and provide additional information and resources.

In summary, Insomnia is an unusually personalized treatise on the challenges of this misunderstood disorder and an offering of support to fellow sufferers. The book also serves to educate readers, who are providers, to the difficulties encountered by individuals with treatment resistant insomnia. Insomniac provides the medical reader with advices as to how to avoid the pitfalls that create a Sisyphean ordeal for the insomniac, who desperately wants a cure for the endless empty pursuit of sleep, in particular, the particular need for sensitivity and compassion, as is the case for the treatment of any chronic disabling medical condition for which symptom improvement is a more realistic goal than remission or cure. Insomnia is thoroughly researched book for providers to recommend to their patients, as well as to deepen the provider's capacity for empathy and emotional understanding of this disorder. Dr. Greene is a passionate and energetic advocate for insomnia sufferers everywhere!

DISCLOSURE STATEMENT

The authors have indicated no financial conflicts of interest.

CITATION

Ralls FM, Abrams SK. Insomniac. J Clin Sleep Med 2015;11(8):959–960.