Current Problems in the Diagnosis and Treatment of Chronic Insomnia

CURRENT PROBLEMS IN THE DIAGNOSIS AND TREATMENT OF CHRONIC INSOMNIA QUENTIN R. REGESTEIN* and PETER REICHf Recently, interest has grown in the diagnosis and treatment of sleep disorders. Over 2 decades of laboratory research have yielded information that may further rationalize treatment ofdisordered sleep. Reviews have appeared discussing newer understanding and treatments for sleep problems [1, 2], and attempts are being made to forge standardized classifications for sleep disorders. Special clinics for the management of these problems are now being organized upon the notion that greater specificity in the diagnosis and treatment of sleep disorders is at hand. Insomnia is perhaps the most common sleep disorder faced by physicians . Insomnia must be distinguished from lack of sleep. Only a tinyfraction of insomniacs is ever objectively examined for the amount of sleep actually obtained, and such examinations when done last but 1 or 2 nights. The results of the examination, when done, are not always consistent with the patient's estimation of sleep loss, yet the patient may continue to complain of insomnia in the absence of objective substantiation ofsleep loss and persist in his demands for relief. For these reasons, we define insomnia as the complaint of sleep loss. Despite the years of clinical experience in treating insomnia and the added understanding of sleep more recently accrued from research, there remain several problems that prevent agreement on how to classify insomnia. Specificity in diagnosing and treating insomnia is therefore hindered. This paper is meant to articulate these problems in order to reconcile for the practitioner the broad, prolonged clinical experience accumulated with insomnia and the relative lack of specificity for its treatment. We will attempt to describe some of the difficulties surround- *Sleep Clinic, Division of Psychiatry, Department of Medicine, Peter Bent Brigham Hospital, 721 Huntington Avenue, Boston, Massachusetts 02115; associate in medicine and assistant professor of psychiatry, Harvard Medical School. tPhysician, Peter Bent Brigham Hospital; and associate professor of psychiatry, Harvard Medical School.© 1978 by The University of Chicago. 0031-5982/78/2102-0006S01.00 232 I Quentin R. Regestein and Peter Reich ¦ Chronic Insomnia ing both the diagnosis and the treatment of insomnia, in order, we hope, to guide further attempts to understand and relieve insomnia patients. Diagnosis Five percent of adult patients from a general medical practice presented complained of insomnia [3], 20 percent in a similar group admitted some sort of sleep disturbance [3], and 45 percent of adults in an epidemiological survey reported difficulties in falling asleep or staying asleep [4]. This remarkable prevalence may contribute to the lack of systematic classification for insomnia. Chronic insomnia is so common that some may consider it a normal experience rather than a pathological problem [5]. Although chronic insomnia may signify severe mental or physical derangement and correlate with augmented death rates [6], much insomnia is mild and temporary. A complaint that subsides rather than persists excites little interest. Nevertheless, much insomnia remains chronic, poses great difficulty for patient and practitioner, and still remains unclassified. The frequency of psychopathology among insomniac patients provides a second reason why insomnia has not been classified. Insomnia can stem from mental problems of all kinds, and many of these are not rapidly treatable. Chronic insomniacs are said to be complaining, oversensitive people [7]. In two series ofinsomnia patients, over 85% ofthose 274 subjects tested showed pathological scores on the Minnesota Multiphasic Personality Inventory, an elevation in the depression scale being most common [8, 9]. Even poor sleepers, discovered through research questionnaires rather than through clinical practice, prove to be anxious, depressed, obsessively worried types [10]. Furthermore, many insomniac patients depend on drugs [H]. Chronic insomnia, therefore, associated with chronic psychological troubles and complicated by drug abuse, may be considered an unattractive problem by many physicians. In these respects it resembles alcoholism by inviting disproportionately small clinical interest. Perhaps, for this reason, characterizing insomnia has recently been left to the psychiatrists, even though prescribing for insomnia is done mostly by other physicians [12]. Certain difficulties arise whenever conditions involving much psychopathology are categorized. The rich diversity of personalities and psychological disorders are not neatly categorized. They are, furthermore , enmeshed in the unique complexity of behavioral traits that characterize every person. Psychiatric nosology, therefore...