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Chapter 4 INSOMNIA: RE SEARCH FINDINGS, DIAGNOSTIC APPROACHES, AND THERAPEUTIC OPTIONS A. The Meaning of Insomnia Insomnia is a subjective complaint that is related to or caused by a variety of disorders. As with many other types of subjective distress (dyspepsia, or back pain), much ignorance surrounds the nature of the problem and the value of the relief commonly provided in modern health care. Most health care professionals have assumed that patients who complain of insomnia accurately describe their night-time sleep. When this assumption has been examined in the clinical sleep laboratory, however, surprising findings emerged: in many cases the actual sleep of patients complaining of insomnia is hardly disturbed; there is an enormous overlap in the objective laboratory measures of sleep between insomniac patients and age-matched, normal controls.* In some cases, the complaint of insomnia is completely unrelated to sleep or to daytime alertness. Although many sleep laboratory studies have shown, that, as a group, insomniacs take longer to fall asleep, sleep less, have less delta sleep, and have lower sleep efficiency than do normals, there also are well-documented cases of insomniac patients who fall asleep within 10-15 minutes and who sleep 7-8 hours per night. 1/-4/ Some insomniacs show greater variability in sleep measures from night to night than normal controls; it has been hypo- thesized that some of their suffering results from their inability to predict when they will have a good or bad night. 3/,5/ Among persons who do not complain of insomnia, some sleep very little and do not consider themselves to be insomniacs. One report describes two normal, healthy men who averaged about three hours of sleep per night when monitored nightly for seven days. 6/ Another describes the case of a 70-year-old woman whose typical 52 minutes of sleep per 24 hours was confirmed in the laboratory. 7/ She re- ported that she had been sleeping this way since her teens with no ill effects. *A comprehensive tabulation of the data upon which these conclusions are based is included in the Technical Supplement to this report. -81

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extent study, sleep, On the other hand, insomnia patients tend to of their difficulties. In virtually every sleep laboratory insomniacs have had great difficulty in correctly assessing their although their subjective estimates usually vary in the same In a major sleep labor- latencv was overestimate the - direction as objective findings. 1/-3/, 8/-12/ atory study of 122 patients, for example, sleep latency was estimated by the patients to be 62 minutes, but was only 26 minutes by EEG crite- ~ - than two-fold. 1/ Actual total sleep time was 342 minutes, but estimated sleep time was 273 minutes, a difference of over an hour. In a classic case reported by Zung, a middle-aged woman with a 25 year history of insomnia slept for four nights in the sleep laboratory. 2/ She fell asleep quickly, slept over eight hours per night, and had normal architecture of sleep stages. Each morning, however, she reported that she "didn't sleep a wink." rota, an exaggeration ot more than two-fold. 1/ Figure 1 is a conceptualization of the overlap in objective ~ ~ ~ and patients with insomnia - to be significantly sleep measures in non-complaining controls complaints, in which the means have been found different between the two groups. Insomnia Mean Normal Mean - A// Normals it\\\>,: I nsomniacs Overlap LONGER AND MORE EFFICIENT SLEEP -82-

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Studies suggest that many non-complaining middle-aged adults have sleep measures that have in the past been deemed impressive in insomniacs. Given the obvious heterogeneity of the insomnia population group, means and standard deviations of sleep measures can be very misleading. One must look at individual patients, rather than group data. For example, in one study referred to above, 58 (nearly half) of the 122 chronic insomniacs consistently fell asleep in less than 15 minutes, and many literally fell asleep instantaneously in spite of claiming they were unable to fall asleep the next morning. 1/, 12/ It is likely that the means conceal crucial diagnostic and etiological differences between patients who actually fall asleep promptly and patients who require several hours to fall asleep. Objective sleep measures alone have proven inadequate in understanding the causes of insomnia and providing confir- mation of ''effectiveness" for its relief. What accounts for insomnia complaints by patients whose objective measures of sleep seem to be adequate? -- Controls and insomniacs may differ in their thresholds for complaining of poor sleep. Given this framework, normal subjects are able to endure a certain amount of sleep fragmentation, sleep reduction, and so forth with no significant consequences. When some other dysphoria, such as anxiety or depression, is added to the picture, the threshold for sleep complaint may decrease. -- The discrepancies in many patients' data could be explained on the basis of fundamental differences in daily need for sleep. Thus, a 50 year old patient who sleeps 7.5 hours a night and complains of insomnia night be a person who requires 9.5 hours nightly to experience restora- tion and to maintain optimal alertness throughout the day. Such a question could probably be resolved by attempting to extend the total amount of sleep. But because very few individuals after the age of 50 are able to sleep for long periods of time without significant periods of wakefulness, the amount of time that such an individual might have to spend in bed in order to accumulate 9.5 hours of sleep could be be prohibitive. -- The classical sleep measures may not be the best way to assess adequacy of sleep. This is a controversial issue, because certain investigators feel that total sleep time is the only pertinent variable. It could be, however, that recently discovered factors such as EEG spindle or delta activity or measures of body movements will yield better clues to the restorative adequacy of sleep. -- Certain individuals may sleep at a higher level of physiological activation than other persons. 4/ Thus, some insomniacs who fall asleep in lo minutes and assume it is one hour may have such heightened activa- tion that they perceive themselves to be awake, however dimly, although they are really asleep. -83-

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- Insomnia and the adequacy of nocturnal sleep may depend more on circadian rhythm properties than on the sleep measures themselves. It has been shown that there is a rhythm in sleepiness and fatigue, particularly in jet lag or in shift work, that can be fairly independent of amount of sleep and when sleep is taken. -- There could be an abnormally heightened response to partial sleep loss. If it is assumed that daytime sleepiness is a consequence of the reduction of sleep below some optimum, it is possible that this response in some people is manifested by exaggerated sleepiness from relatively minor sleep disturbance. -- The complaint of insomnia or disturbed sleep may not refer directly to sleep at all, but to an aspect of anxiety or depression. In these cases, the inability to sleep may become a relatively respectable, acceptable complaint. This formulation is supported by the work of Kales and associates 13/ who have reported Minnesota Multiphasic Personality Inventory (MMPI) studies in groups of patients complaining of insomnia and consistently find approximately 85 percent showing pathological elevation of one or more of the subscales. There is widespread feeling among researchers and clinicians that most complaints of insomnia are associated with depression and emotional problems. 14/ Issues of cause-and-effect and precise prevalence remain controversial and unresolved. The above observations illustrate some of the problems faced by the clinician. In treating a patient who complains, for example, that he requires an hour to fall sleep, the physician must remember (a) that it is likely that the patient falls asleep considerably more quickly, (b) that under the best of circumstances, a hypnotic will probably shorten the objective sleep latency by only 10 to 20 minutes; and (c) that although the patient's estimate of the difficulty may be exagger- ated, his subjective distress is real. At the present time, little is known about the relationship between the objective characteristics of sleep and subjective satisfaction. It is unclear why some people complain about their sleep when they sleep eight hours, while others do not when they sleep one hour. Nor is it known if hypnotics are more effective in insomniac patients with objective sleep disturbance than in those without. The functions of sleep are basically unknown. In terms of patient education, the physician should remember that some of the anxiety experienced by insomniac patients results from prior erroneous teach- ing about the functions of sleep. Everyone has heard that it is neces- sary to get "plenty of sleep" in order to maintain good health or to recover from illness. These common attitudes were reinforced to an -84-

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unfortunate degree by early sleep laboratory experiments which prematurely suggested that deprivation of total sleep, REM sleep, or Stage 4 sleep might cause serious psychopathology. It now appears that the overall effects of REM sleep deprivation or Stage 4 deprivation are, at most, slight and subtle. There is little evidence that short term sleep deprivation increases the risk of mental or physical illness. However, epidemiological studies suggest that self-reported short 15/-16/ (and long) 16/ sleep may be related in the long run to increased mor- tality rates. It can be helpful for patients to be told that there are wide individual differences in the amount of sleep people seem to need. In a similar vein, current evidence suggests that the effect of a hypnotic drug on a specific sleep stage is not of major importance, and that choosing between hypnotics should not be based primarily on their relative effects on sleep stages. It seems reasonable to choose the drug with the least disruptive effect on sleep stages. All of the currently marketed prescription drugs appear, however, to alter sleep stages in one way or another. While flurazepam, for example, has a relatively small effect on REM sleep, it is a highly potent suppressor of Stage 3 and 4. On the other hand, the barbiturates, glutethimide, ethchlorvynol, the antihistamines, and the over-the-counter medications all tend to suppress REM sleep. The less potent hypnotics, such as L-tryptophan and chloral hydrate have the least effects on sleep stages-. One possible complication of REM suppressing drugs, however, should be considered. When these drugs are discontinued, total amounts of REM sleep on subsequent nights may increase dramatically for several days or weeks. This so-called "REM rebound" may be associated with vivid dreams or nightmares. Potentially, the REM rebound could be a period of special vulnerability in patients with nocturnal gastric hyperacidity, nocturnal angina, or other medical disorders which are intensified during REM sleep. "Drug withdrawal insomnia" or "rebound insomnia" has been identified following discontinuation of most REM- suppressing hypnotics and, recently, following discontinuation of some benzodiazepines, which mainly suppress Stages 3 and 4. The physician should keep in mind that sleep tends to become shorter, shallower, and more fragmented, with more awakenings each night, as part of the normal aging process. These tendencies are probably exaggerated in patients with insomnia, depression, or many other disturbing medical or environmental conditions. Because of the confusion engendered by the complaint (and concept) of insomnia, a closer look from the point of view of sleep research may be helpful. -85-

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The Complaint of Being Unable to Fall Asleep (Sleep Latency Problem) Falling asleep quickly is an essential component of subjectively "good" sleep and is taken for granted by most people. A long delay in falling asleep is experienced as dysphoric. It is now known that sleep and wakefulness are part of a 24-hour rhythmic process, and there is a certain time of the day when the organism begins to experience a readi- ness for sleep. If the bedtime is not coordinated with this time, there could be a sleep latency problem. Because this fact is not generally understood, the sleep disorders specialist often finds that patients tend to be somewhat casual about the regularity of their bedtime - occasionally complaining of "insomnia" when they go to bed very early in the evening. Furthermore, there is very little data on what constitutes the threshold for complaining about this problem. Many complex factors can enter into a decision to seek medical advice: the actual number of nights the inability to fall asleep is experienced; the presumed etiology -- if the patient perceives an obvious cause he is less likely to complain than if the problem appears to have no cause; convenience -- thus, if one has a routine appointment with one's physician, one is likely to mention the perceived inability to fall asleep, whereas one may delay bringing the problem to the attention of the physician if a special effort is required to make an appointment; the effect on daytime activities -- a problem may be endured on vacation when there is a possi- bility of sleeping late in the morning, whereas if the same problem is felt to interfere with one's working situation, a physician might be consulted; finally, a patient's tendency to use medication pro- phylactically could be a factor. The Complaint of Being Unable to Stay Asleep (Sleep Maintenance Problem) Some people complain that they have no trouble falling asleep, but inevitably wake up during the night, either many times, or for a long period of time, or both. Once again, this type of complaint can be very complicated. Is there too much wine at dinner? A noisy environment? A strange bed? A bed-partner who snores loudly, moves frequently, etc.? Emotional upset -- especially depression? An inappropriate sleeping time? Here again the duration and intensity of the problem are issues. The Complaint of Daytime Consequences Although it is remotely possible in some patients that the total dysphoria of a sleep disturbance is the anxiety or boredom of lying awake at night, there is general agreement among sleep disorders specialists that a complaint of insomnia cannot be viewed as a sign of a pathological sleep disturbance unless there is some daytime conse- quence. However' when dealing with patients who complain of disturbed -86-

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sleep, physicians may neglect to inquire about the effect of the pre- sumed sleep loss upon daytime function. Assessment of daytime problems consequent to nocturnal sleep dis- turbance is complex. It is well known that muscular activity can counteract sleepiness. _ / General pleasantness or unpleasantness of the life situation interacts, as do soporific situations like a hot room, a boring lecture, a heavy meal, use of alcohol, and so forth. Often a most difficult medical decision involves differentiating fatigue and tiredness due to sleep disturbance from alterations in mood and activity changes due to depression. B. Types of Insomnia Only in the past few years have a number of interdisciplinary cen- ters been established specifically to offer their services in the inten- sive evaluation of individual patients with sleep complaints. The aim with each patient is to make a specific etiologic diagnosis, and to recommend or initiate the most appropriate treatment. By compiling the results of individual cases, sleep disorders centers have thus begun the first comprehensive empirical case series analysis of the complaint of insomnia. In 1978, after nearly two years of deliberations and comparisons of case series, the Association of Sleep Disorders Centers (ASDC) proposed a standard diagnostic classification of "Disorders of Initiating and Maintaining Sleep" (DIMS). This is shown in Table 1, which also includes relevant parts of their classification of "Biological Rhythms Distur- bances" which may also give rise to the complaint of insomnia. This nosology undoubtedly will change as further progress is made in under- standing sleep disorders. In a few categories, data and experience were deficient and anecdotal information was utilized for the sake of com- prehensiveness. Several sleep disorders centers are now using this classification. Some diagnoses do not include a specific etiology, and in most instances no good data are available on treatment. However, the formulation of a standard classification is an essential prelude to further progress in cooperative case series studies and to more specific evaluation of the efficacy of hypnotic drugs and other therapeutic measures. The following is a description of most of the specific diagnoses, modified from the ASDC nosology to make the material useful to practicing physicians. Transient and Situational Insomnia Acute insomnia may arise from a number of sudden changes in life, such as medical, surgical, or traumatic conditions; admission to a -87-

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Table 1 DIAGNOSTIC CLASSIFICATION OF INSOMNIA* I. Disorders of Initiating and Maintaining Sleep: DIMS (The Insomnias) 1. Psvehonhv~iolo~i c~1 a. Transient Situational b. Persistent 2. Psychiatric Disturbances associated with a. Personality and Neurotic Character Disorders b. Affective Disorders c. Acute Schizophrenia and Other Psychoses 3. Use of Drugs and Alcohol . associated with a. Tolerance to or Withdrawal from CNS Depressants b. Sustained Use of CNS Stimulants Sustained Use or Withdrawal of Other Drugs d-. Habitual Use or Withdrawal of Alcohol Sleep Induced Ventilatory Impairment . a. Sleep Apnea b. Hypoventilation Syndromes Nocturnal lIyoclonus and "Restless Legs" Syndromes - associated with a. Nocturnal Myoclonus b. "Restless Legs" Restless Legs with Nocturnal Myoclonus 6. associated with Other Medical, Toxic, and Environmental Conditions 7. Childhood Onset Centers *Adapted from the Nosology Committee, Association of Sleep Disorder -88-

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Table 1 (continued) Other DIMS Conditions associated with a. Parasomnias (specify conditions) b. Repeated REDS Interruptions Atypical Polysomnographic Features Not Otherwise Specified 9. No DIMS Abnormality a. Short Sleeper ("Healthy Insomniac") b. Subjective DIMS Complaints without Objective Findings c. Not Otherwise Specified II. Dyssomnias Associated with Disruptions of 24-Hour Sleep-Wake Cycle 1. Phase Shift associated with a. Rapid Time Zone Change ("Jet Lag" Syndrome) b. Unconventional or Changing Sleep-Work Schedule (Shift Work) Delayed Sleep Phase 2. Non-24 Hour Sleep-Wake ~y~-~drome - 3. Irregular Sleep-Wake Pattern -89-

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hospital or sleeping in any new environment; personal stress and anxiety, as in bereavement; or disturbances of biological rhythms, such as "jet lag" or shift work. Other commonly stressful conditions include occupa- tional changes, moving to a new location, severe illness in a close rela- tive or friend, termination of a romantic relationship, and test anxiety. Acute forms of insomnia usually respond to the passage of time, patient education, or the judicious use of hypnotics. However, firmly established treatments are lacking in some situations. In the case of jet lag, for example, administration of a hypnotic may increase total sleep time without improving subjective well being. 18/ In this condition, the actual loss of sleep is probably less disruptive than the deviation from the schedule imposed by one's internal biological clock. Insomnia Associated with Mental Disorders Psychological symptoms -- varying degrees of depression, anxiety, concern about physical well-being, and "nervousness" are common in insomniac patients. In a standard psychological screening test, such as the Minnesota Multi-Personality Inventory (MMPI), most insomniac patients show evidence of psychopathology, particularly on the depres- sion and hypochondriasis scales. 1/,13/,19/,20/ Before treating the patient, therefore, the physician must gauge the severity of the psychological disturbances, if any, and decide whether these distur- bances are sufficient to make a psychiatric diagnosis, such as depres- sion, mania, organic brain syndrome, alcoholism, drug addiction, schizophrenia, hypochondriasis, anxiety, neurosis, or personality disorder. This involves a careful history and mental status examina- tion, as well as additional history from relatives, friends and co-workers when appropriate. Not only do psychiatric illnesses fail to respond to hypnotics, but also hypnotics may be used by disturbed individuals for suicide. In one study, more than half of those who committed suicide by overdose had received a medical prescription for lethal amounts of a hypnotic within one week of death. 21/ A British study found that many patients who committed suicide by hypnotic ingestion had been taking sleeping pills for years, often renewing their prescriptions by telephone calls to the doctor's receptionist without any regular physician contact. 22/ Depressive illness may be classified as primary or secondary. Primary depression occurs in patients with primary affective illness, that is, in the absence of another primary psychiatric or medical illness. Primary affective illness includes unipolar (one or more depressive episodes) and bipolar depressive illness (a history of both depressive and manic episodes). Secondary depression may occur in patients with alcoholism, drug addiction, schizophrenia, obsessive- compulsive disorders, hysteria, passive dependent and pas sive-agressive disorders, and other psychiatric illnesses. It may also occur in patients with primary medical illnesses, such as Addison's Disease, hyperparathyroidism, or pancreatic carcinoma. 90

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In recognizing depression, the physician should be alert to the mental, physiological, and social symptoms seen in depressed patients (Table 2~. The duration of symptoms is important in establishing the diagnosis of a depressive illness since many of these same symptoms may occur briefly in acute situational reactions, such as mourning or severe disappointment. The physician's recognition of suicidal risk is of particular importance not only in patients with symptoms of depression, but also those who display signs of anxiety, irritability, hysteria, sociopathy, impulsiveness, alcoholism, or schizophrenia. As Murphy 23/ points out, the first and most important step is for the physician to ask himself "Can this patient commit suicide?" Once this is a consideration in the physician's mind, he should ask the patient several broad but tactful questions, such as "How has your mood been lately?" or "How badly have you been feeling?" He must ask specific questions about suicidal ideas, such as "Have you felt badly enough to wish you were dead?" "Have you ever thought of doing anything to yourself?" The patient with a specific suicide plan, and the means to carry it out, is at grave risk, and prompt hospitalization should be considered. Factors that increase risk of successful suicide include male sex, age greater than 40, social isola- tion, history of prior suicide attempts, delusions of somatic illness, troublesome physical illness, and uncontrolled drinking. 23/ Although men are more likely to successfully commit sucide than women, women are more likely to use drugs when they attempt or suceed in suicide. The prescription of sedatives or hypnotics in fatal doses to a suicidal patient may be a serious lapse of medical judgment. It implies, first, that the physician has failed to recognize the true diagnosis of depression and suicidal risk, and, secondly, that he has provided the patient with the means to kill himself. Since most hypnotics can be fatal when 10 to 30 dosage units are ingested, the amount prescribed in the modal prescription for hypnotics in this country -- 30 pills -- is sufficient to cause death or prolonged coma if taken in overdose. Even the benzodiazepines, which are rarely lethal when ingested alone, can be fatal when combined with alcohol or other drugs. Little justification exists for the general proposition that the suicidal patient will kill himself by some other means if denied the use of pills. This proposition may be true for a few patients; however, many are clearly ambivalent about dying and the suicidal attempt is often a "cry for help," impulsive or manipulative. Since generally effective treatments exist for depression, every effort should be made to recognize depression and suicidal risk and to treat it appropriately. Suffice it to say, treatment of depression is aimed at the reduction of depression and prevention of further episodes of affective illness. Among the important factors in treatment are -91- a

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that the treatment would probably be of no benefit for about four weeks. However, the group receiving relaxation training alone also improved, so the specificity of the desensitization aspects of the treatment is in question. Classical conditioning procedures have been described as useful in the Russian 64/ and German 65/ literature. One example 66/ of this approach was the administration of methohexital to induce sleep in a patient with anxiety, phobias, and hyposomnia while he listened to a metronome. The patient would then turn on the metronome at bedtime. Although this procedure was clinically beneficial in this and another case, 67/ there are no data from controlled studies. Stimulus control studies of insomnia are based on the proposition that the insomniac has difficulty because the bedroom environment has become associated with activities incompatible with sleep (worrying, eating, watching television). The patient is instructed to get into bed only when sleepy, and to immediately leave the bedroom if he finds himself engaged in any activity except sleep or sex. A com- parison of stimulus control, progressive relaxation, self-relaxation and no treatment in 78 subjects disclosed the greatest reduction in subjective sleep latencies in the stimulus control group, followed by the progressive relaxation group; and these were both signifi- cantly better than the other two groups. _ / This approach has fared well in subsequent studies, _ /-70/ and might profitably be examined further in controlled studies of insomniacs. Attributional therapy is based on the concept that manipulation of a subject's understanding of the source of his difficulty might be therapeutic. In an effort to externalize the perceived source of arousal, 71/ when patients were told that a pill they were receiving would further stimulate them, they went to sleep more quickly. Other subjects who were told that a pill was a sedative stayed awake longer, presumably because they became distressed that they were having difficulty falling asleep even when taking a "sedative," and the resultant anxiety compounded the sleep disturbance. This notion has suffered in replication studies, however, and is unproved. 72/-73/ In another variation on attribution therapy, it was suggested that an insomniac's sleep may improve if he can learn to attribute to himself the ability to go to sleep easily. 74/ Insomniacs received a combination treatment that included a high dose of chloral hydrate (1000 mg), relaxation training, and practical suggestions such as regularizing their sleep habits. Those who improved were divided into two groups. One group was told that the dosage they received was maximally effective and hence the implication was that their -108-

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improvement was due to the medication. The other group was told that their dosage was only minimally effective, and hence that their improve- ment was due to their own efforts. The chloral hydrate was then discontinued, and it was found that the latter group continued to do well, while the former group became worse. One case report suggests the possibility that self-monitoring, in lieu of any behavioral training techniques, may be an effective treatment in certain patients complaining of insomnia. 75/ The case report showed dramatic improvement in one patient who was simply asked to keep daily records of his sleep latency, the time he awoke, and the amount of time he spent napping. Again, however, specific replica- tion studies have not been reported. insomnia . Behavioral self-management emphasizes a combination of specific techniques, such as progressive relaxation and a cognitive learning theory approach. 76/ 77/ With the latter the patient is asked to keep diaries and to explore and decrease the stimuli which raise the anxiety-tension level in the daytime. Modification of work and domestic schedules is used to decrease anxiety producing stimuli in the evening. Specific internal arousal conditioning factors such as internal dialogues after lights out, are discovered and dealt with. All the techniques emphasize mastery and aid the patient to overcome a sense of impotence in dealing with his sleep problem. ~ ~ ~ incorporated in the treatment regimen for in- These techniques somniacs seen at are the Stress Reduction Clinic at the Stanford Medical Center. Successful results have been described in individual cases (including some who had been drug dependent) using this multi-faceted treatment, though a case series and controlled studies are needed to establish the usefulness of this approach. -109-

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REFERENCES 1 2 ,.. 4 5 6 7 8 9 10 Carskadon, M., Dement, W., Mitler, W., Guilleminault, C., Zarcone, V and Spiegel, R., Self-report versus sleep laboratory findings in 122 drug-free subjects with the complaint of chronic insomnia. American Journal of Psychiatry 133:1382-1388, 1976. Zung, W., The treatment of insomnia with antidepressant drugs. Psychophysiology 5:234, 1968. Frankel, B., Coursey, R., Buchbinder, R., and Snyder, F., Recorded and reported sleep in chronic primary insomnia. Archives of General Psychiatry 33:615-623, 1976. Monroe, L., Psychological and physiological differences between good and poor sleepers. Journal of Abnormal Psychology 72:255-264, 1967. Williams, R., Hursch, C. and Karacan, I., Between-subject variability and night-to-night variability in insomniacs and normal controls. Sleep Research 1:154, 1972. Jones, H. and Oswald, I., Two cases of healthy insomnia. Electroen- cephalography and Clinical Neurophysiology 24:378-380, 1968. Meddes, R., Person, A. and Langford, G., An extreme cans-- of healthy insomnia. Electroencephalography and Clinical Neurophys~ology 35: 213-214, 1973. ., Bixler, E., Kales, A., Leo, I. and Slys, T., A comparison of subjective estimates and objective sleep laboratory findings in insomniac patients. Sleep Research 2:143, 1973. Hoddes, Z., Carskadon, M., Phillips, R., Zarcone, V. and Dement, W. Total sleep times in insomniacs. Sleep Research 1:152, 1972. Roth, T., Lutz, T., Kramer, M. and Tietz, E., The relationship between objective and subjective evaluations of sleep in insomniacs. Sleep Research 6:178, 1977. -110-

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11 12 13 14 15 16 17 18 19 20 Carskadon, M., Mitler, M., Billiard, M., Phillips, R. and Dement, W A comparison of insomniacs and normals: Total sleep time and sleep latency. Sleep Research 4:212, 1975. Scherer, M. and Dement, W.C., Personal communication. ., Kales, A., Caldwell, A.B., Preston, T.A., Healey, J. and Kales, J.D., Personality patterns in insomnia. Archives of General Psychiatry 33: 1128-1134, 1976. Hartmann, E., The Sleeping Pill (New Haven: Yale University Press), 1978. Belloc, N.B., Relationship of health practices and mortality. Preventive Medicine 2:67-81, 1973. Kripke, DeFe ~ Simons, R.M., Garfinkel, L. and Hammond, E.C., Sleep duration, insomnia and sleeping pill use e Archives of General Psychiatry 36:103-116, 1979. Kleitman, N., Sleep and Wakefulness (Chicago: University of Chicago Press), 1963. Pollack, C.P., McGregor, P., Weitzman, E.D., The effect of flurazepam on daytime sleep after acute-wake cycle reversal. Sleep Research 4: 112, 1975. Coursey, R.D., Buschsdaum, M. and Frankel, B.L., Personality measures and evoked responses in chronic insomniacs. Journal of Abnormal Psychology 84:239-249, 1975. Roth, T. and Kramer, M., The nature of insomnia: a descriptive sum~ary of sleep clinic population (abstract) in Sleep Research 4: 234, 1975. 111

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21 22 23 24 25 26 27 28 29 30 Murphy, G.E., The physicians responsibility for suicide I: An error of commission. Annals of Internal Medicine 82:301-304, 1975. Barraclough, B.M., Nelson, B., Bunch, J., and Sainsburg, P. Suicide and barbiturate prescribing. The Journal of the Royal College of General Practitioners 21:645-653, 1971. Murphy, G.E., Recognition of suicidal risk: The phyisician's responsibility. Southern Medical Journal 62: 723-728,1969. Klerman, G.L., DiMascio, A., Weissman, M., Prusoff, B., and Paykell, E.S., Treatment of depression by drugs and psychotherapy. American Journal of Psychiatry 131:186-191, February 1974. DiMascio, A., Weissman, M., Prusoff, B., Neu, C., and Klerman, G., Differential symptom reduction by drugs and psycho-therapy in acute depression. Presentation of the Society for Psycho-therapy Research, June 1978, Toronto. Kales, A., Bixler, E., Tan, T., Scharf, M.D., and Kales, J.D., Chronic hypnotic drug use. Journal of the American Medical Association 227 :513-7, 1974. Moore, R.A., Management of the Alcoholic, in Controversy in Psychiatry (Philadelphia: W.B. Saunders Company), 1978, pp. 305-325. Adamson, J. and Burdick, J.A., Sleep of dry alcoholics. Archives of General Psychiatry 28: 146-149, 1973. Guilleminault, C., Tilkien, A. and Dement, W., The sleep apnea syndromes. Annual Review of Medicine 27 :465-484, 1974. Guilleminault, C., Eldridge, F.L., Phillips, J.R., Dement, W.C. Two occult causes of insomnia and their therapeutic problems Archives of General Psychiatry 33:1241-5, 1976. -112-

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