Sleeping Pills, Insomnia, and Medical Practice Report of a Study (1979) / Chapter Skim
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Chapter 4: Insomnia: Research Findings, Diagnostic Approaches, and Therapeutic Options
Chapter 4: Insomnia: Research Findings, Diagnostic Approaches, and Therapeutic Options
Pages 81-118
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From page 81... ...
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.
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From page 82... ...
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.
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From page 83... ...
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.
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From page 84... ...
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.
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From page 85... ...
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-.
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From page 86... ...
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 consequence. However' when dealing with patients who complain of disturbed -86
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From page 87... ...
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)
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From page 88... ...
Hypoventilation Syndromes Nocturnal lIyoclonus and "Restless Legs" Syndromes associated with a. Nocturnal Myoclonus b.
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From page 89... ...
Phase Shift associated with a. Rapid Time Zone Change ("Jet Lag" Syndrome)
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From page 90... ...
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)
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From page 91... ...
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.
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From page 93... ...
Some chronic insomniac patients receiving prolonged treatment with hypnotics appear to sleep worse than similar patients without hypnotic treatment. 26/ Some of these patients -93
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From page 94... ...
Of particular importance is sleep apnea. 29/-32/ The administration of hypnotic drugs to patients with sleep apnea may be fatal.
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From page 95... ...
Patients suspected of having this syndrome should be referred to a sleep disorders center for specialized evaluation, including polysomnography, which involves all-night recordings of the BEG, eye movements, electromyogram, electrocardiogram, heart rate, respiration, chest movements, blood gases, and other measures. Following the discovery of this syndrome in 1973, 31/ all patients with chronic insomnia referred to the Stanford University Sleep Disorders Center were routinely evaluated for sleep-related respiratory problems.
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From page 96... ...
35/ Most sleep disorders specialists now recognize the existence of sleep apnea syndromes as possible causes of unsatisfactory sleep in patients who have been referred to them for specialized evaluation. Yet to be established is the prevalence of these syndromes -especially in insomnia patients in general medical practices, in the general population, and in the elderly.
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From page 97... ...
18/ Insomnia Associated with Medical Disorders Since insomnia may be associated with practically any medical or surgical condition, evaluation of the chronic insomniac patient must include a thorough medical history, physical examination, and appropriate laboratory examinations. Insomnia is rarely the presenting chief complaint of a medical disorder, but it can be in such conditions as orthopnea, paroxysmal nocturnal dyspnea, dementia ("sun-downer syndrome")
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From page 98... ...
In a case series of 141 consecutive insomniacs studied in the sleep laboratory at Dartmouth Medical School, 51 (31 percent) were classified as "idiopathic" insomniacs.
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From page 99... ...
41/ No case series or controlled studies have as yet been reported, however, which establish the specific utility of these treatment approaches. Most sleep-disorder specialists do not recommend hypnotic drugs as the primary form of therapy in the treatment of most patients with persistent insomnia.
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From page 100... ...
It is desirable to know the usual bedtime and its regularity, how long does it usually take to fall asleep, and what are the usual events prior to turning out the lights. Where does the patient sleep and what are the conditions?
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From page 101... ...
Most sleep disorders specialists are dubious about its value and concerned about its risks. Leading authorities disagree or are uncertain about the indications for treatment with hypnotics, even in the short run.
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From page 102... ...
, and in suicidal overdose, coma and death can occur at relatively low doses (10-20 dosage units)
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From page 103... ...
In the case of flurazepam, only two studies have been published, each involving five insomniac patients who were studied for four weeks in the sleep laboratory while receiving the drug nightly; the drug appeared to retain many of its effects on sleep during these studies, but these data are obviously too limited to provide firm guidelines. Many of the other hypnotic hazards have been previously mentioned.
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From page 104... ...
Disruption of normal sleep stages 14. Liability for use in drug abuse (intoxication, addiction)
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From page 105... ...
Particularly severe cases may be referred to a sleep disorders clinic. Long time users of hypnotics who are satisfied pose different problems.
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From page 106... ...
biofeedback, progressive relaxation and autogenic training. EMG biofeedback is performed by electronically measuring the tension in a muscle group (usually on the forehead)
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From page 107... ...
50/-53/ Among studies that controlled for subject expectation and similar factors are those of Borkovec and Fowles, 54/ who found that progressive relaxation was of some benefit in questionnaire-selected college students, but that improvement was no greater than in a self-relaxation group, and that of Nicassio and Bootzin, 55/ which was more hopeful about the benefits of progressive relaxation and autogenic training in volunteers who reported long sleep latencies. More recent studies have added EEG measures of sleep onset latency to the experimental protocols.
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From page 108... ...
A comparison 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 significantly 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.
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From page 109... ...
insomnia . Behavioral self-management emphasizes a combination of specific techniques, such as progressive relaxation and a cognitive learning theory approach.
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From page 110... ...
., Bixler, E., Kales, A., Leo, I and Slys, T., A comparison of subjective estimates and objective sleep laboratory findings in insomniac patients.
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From page 111... ...
and Frankel, B.L., Personality measures and evoked responses in chronic insomniacs. Journal of Abnormal Psychology 84:239-249, 1975.
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From page 112... ...
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.
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From page 113... ...
and Russek, E., Prevalence of sleep apnea in chronic insomnia. Sleep Research 5:161, 1976.
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From page 114... ...
, 1978. Jacobson, E., Progressive Relaxation.
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From page 115... ...
and Bootzin, R., A comparison of progressive relaxation and autogenic training as treatments for insomnia. Journal of Abnormal Psychology 83:253-260, 1974.
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From page 116... ...
and Borkovec, T.D., Active and placebo treatment effects of moderate insomnia under counterdemand and positive demand instructions. Journal of Abnormal Psychology 83:157-163, 1974.
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From page 117... ...
and Rosekind, M.R., Treating Insomnia: A Self-Management Approach. Sleep Research Vol.
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