by Steve Danzis
[ bookreviews ]
Gayle Greene's Insomniac is the most insightful and unusual book I have read about sleep disorders. Greene, a professor of literature and women's studies at Scripps College, serves as patient representative on the board of the American Insomnia Association. Although she has no medical training, she regularly attends conferences to stay familiar with the latest research. But the most important knowledge she brings to bear on the subject comes from her personal experience. For much of her life, Greene has struggled to get more than a few hours of sleep a night despite trying nearly every remedy available.
Insomnia is a hidden epidemic. Surveys suggest that 10 to 15 per cent of adults in industrialized countries have chronic insomnia, with much higher rates among the poor, women and the elderly. No one can reliably estimate how many billions of dollars are lost annually from related productivity loss and accidents. Yet little funding exists for basic research into the causes of insomnia. Media coverage of insomnia tends to be superficial, even when it claims a famous victim. After Heath Ledger died from a toxic combination of sleeping pills and other medication, news reports focused on his prescription drug abuse, not on the severe insomnia that plagued him in his final months.
For decades, insomnia research was dominated by the theories of Sigmund Freud, who considered it a symptom of neurosis. Although most contemporary researchers have "deneuroticized" their approach, Greene argues that they still follow Freud's lead in emphasizing psychological over physiological causes. Insomnia is generally seen as a symptom of depression or the result of poor sleep habits. According to the highly influential Diagnostic and Statistical Manual of Mental Disorders (DSM), "A marked preoccupation with and distress due to the inability to sleep may contribute to the development of a vicious cycle: the more the individual strives to sleep, the more frustrated and distressed he or she becomes and the less he or she is able to sleep."
The DSM implies that all insomnia is psychological in origin except when it accompanies a known medical cause, such as apnea or restless-leg syndrome. Insomnia itself is not a disease or a syndrome, but a symptom. Greene thinks that relegating insomnia to the category of symptoms has important consequences on research: "Lacking a name, or having too many names, or having names that are loaded, insomnia fails to rally support. There is no public recognition of a shared affliction and no assault being launched against it. There is nobody saying, 'we're going to fight this thing.'"
The emphasis on psychological explanations of insomnia also interferes with its treatment. Health plans offer less compensation for mental than for physical conditions. And doctors often feel that the patient is largely to blame. Insomniacs are widely stigmatized as complainers and hypochondriacs. Greene once overheard a doctor say at a conference, "The only thing I like to see come through my door less than a kid with ADD is an insomniac." As Jerome Groopman shows in How Doctors Think, such attitudes can profoundly affect patient care, causing doctors to dismiss complaints and overlook serious diseases.
Greene acknowledges that depression and poor sleep habits often accompany insomnia - anyone who goes without sleep for too long is at risk of becoming depressed and anxious about sleep. She also accepts that some insomniacs are helped by cognitive behavioral therapy (CBT), the preferred treatment option among many sleep researchers. CBT is actually a group of therapies that includes sleep restriction, relaxation training, and efforts to change insomniacs' perception of their sleep. This approach requires a high degree of discipline, which may help explain why it has failed to catch on with many insomniacs.
Proponents of CBT have released studies showing good success rates, but Greene is skeptical of these claims. The studies tend to be subjective and rely on small sample sizes. Subjects are carefully screened, and the number of those who fail to complete the treatment are usually not reported. "Will what works with a small group of carefully screened, self-selected, highly motivated subjects actually work with 'real-world' insomniacs?" Greene wonders. She concludes that "it seems that some large claims are being made on the basis of not much evidence, not many subjects studied, and not all that much improvement."
Greene is equally sceptical of pharmaceutical companies, although she appreciates their willingness to take the complaints of insomniacs seriously. Each new sleeping pill is rolled out with great fanfare—and a marketing budget that dwarfs the amount spent on basic research. Companies release studies showing that their drugs do not cause dependency or daytime impairment. Yet most sleeping pills are "me-too drugs," tweaked versions of older pills that target the same neurotransmitter system. Claims of greatly increased safety and effectiveness are contradicted by users who report experiencing memory loss, daytime drowsiness, personality changes, and cognitive impairment. When they stop taking the drug, they may need to overcome a "rebound effect" - insomnia that is much worse than the patient had before taking the drug.
Greene expresses cautious hope that within a decade, more effective sleeping pills will come to market, ones that target different mechanisms of the sleep-wake system. In the meantime, she will continue to cope with her insomnia as best she can. Perhaps the most valuable chapter of her book is the one called 'Bedding Down with the Beast', in which she describes a routine she has cobbled together - the pills she juggles, the foods and activities she avoids, the tricks she uses to calm her 3am thoughts. Greene is certainly no Pollyanna, but she never succumbs to despair: "You can live with this thing. I have lived with it, not gracefully or as well as I might have lived without it (though that might be a delusion), and who knows for how long I'll live with it. But I get by."