Case Studies in Insomnia

256 Pages·1991·25.16 MB·English

by  Arthur J. Spielman

Case Studies
in Insomnia
CRITICAL ISSUES IN PSYCHIATRY
An Educational Series for Residents and Clinicians
Series Editor: Sherwyn M. Woods, M.D., Ph.D.
University of Southern California School of Medicine
Los Angeles, California
Recent volumes in the series:
CASE STUDIES IN INSOMNIA
Edited by Peter J. Hauri, Ph.D.
CLINICAL DISORDERS OF MEMORY
Aman U. Khan, M.D.
CONTEMPORARY PERSPECTIVES ON PSYCHOTHERAPY WITH
LESBIANS AND GAY MEN
Edited by Terry S. Stein, M.D., and Carol J. Cohen, M.D.
DECIPHERING MOTIVATION IN PSYCHOTHERAPY
David M. Allen, M.D.
DIAGNOSTIC AND LABORATORY TESTING IN PSYCHIATRY
Edited by Mark S. Gold, M.D., and A. L. C. Pottash, M.D.
DRUG AND ALCOHOL ABUSE: A Clinical Guide to Diagnosis
and Treatment, Third Edition
Marc A. Schuckit, M.D.
EMERGENCY PSYCHIATRY: Concepts, Methods, and Practices
Edited by Ellen L. Bassuk, M.D., and Ann W. Birk, Ph.D.
ETHNIC PSYCHIATRY
Edited by Charles B. Wilkinson, M.D.
EVALUATION OF THE PSYCHIATRIC PATIENT: A Primer
Seymour L. Halleck, M.D.
NEUROPSYCHIATRIC FEATURES OF MEDICAL DISORDERS
James W. Jefferson, M.D., and John R. Marshall, M.D.
THE RACE AGAINST TIME: Psychotherapy and Psychoanalysis
in the Second Half of Life
Edited by Robert A. Nemiroff, M.D., and Calvin A. Colarusso, M.D.
STATES OF MIND: Configurational Analysis of Individual
Psychology, Second Edition
Mardi J. Horowitz, M.D.
A Continuation Order Plan is available for this series. A continuation order will bring
delivery of each new volume immediately upon publication. Volumes are billed only
upon actual shipment. For further information please contact the publisher.
Case Studies
in Insomnia
Edited by
J.
PETER HAURI, Ph. D.
Mayo Clinic
Rochester, Minnesota
With a Foreword by
WILLIAM C. DEMENT, M.D., Ph.D.
Springer Science+ Business Media, LLC
L1brary of Congress Catalog1ng-1n-Pub11cat1on Data
Case stud1es 1n 1nsomn:a 1 ed1ted by Peter J. Haur1 . w;th a foreword
by W1ll1am C. Dement.
p. cm. -- <Cr1t1cal 1ssues 1n psvchlatryl
Includes b1Dl1ograph1ca1 references and index.
ISBN 978-1-4757-9588-2 ISBN 978-1-4757-9586-8 (eBook)
DOI 10.1007/978-1-4757-9586-8
1. Insomnla--Treatment--Case stud1es. I. Haur1, Peter.
II. Ser1es.
[DNLMo 1. Behav1or Therapy--methods. 2. Insomn1a--psychology.
3. Insomnla--therapy. 4. Psychotherapy--methods. WM 188 C337]
RC548.C37 1991
616.8"498--dc20
DNLM/DLC
for L:brzry of Cc~gress 91-20965
CIP
ISBN 978-1-4757-9588-2
© 1991 Springer Science+ Business Media New York
Originally published by Plenum Publishing Corporation in 1991
Softcover reprint of the hardcover 1 st edition 1991
AII rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
Contributors
Richard P. Allen Sleep Disorders Center, Johns Hopkins University School
of Medicine, Baltimore, Maryland 21224
Richard R. Bootzin Department of Psychology, University of Arizona,
Tucson, Arizona 85721
Andrew J Borson Sleep Disorders Center, Crozer-Chester Medical Center,
Chester, Pennsylvania 19013
William C. Dement Sleep Disorders Center, Stanford University, Palo
Alto, California 94305
Dana Epstein Department of Psychology, University of Arizona, Tucson,
Arizona 85721
Milton K. Erman Sleep Disorders Center, Scripps Clinic and Research
Foundation, La Jolla, California 92037
Judith Flaxman Illinois School of Professional Psychology, Chicago, Illi
nois 60604
Paul B. Glovinsky Department of Psychology, The City College of the City
University of New York, New York, New York 10031 and Insomnia Treat
ment Center, New York, New York 10017
Peter J Hauri Sleep Disorders Center, Mayo Clinic, Rochester, Minnesota
55905
John H. Koewler Sleep Disorders and Research Center, Deaconess Hospi
tal, St. Louis, Missouri 63139
Patricia Lacks Psychology Department, Washington University, St. Louis,
Missouri 63130
v
vi CONTRIBUTORS
Stuart J. Menn Sleep Disorders Center, Scripps Clinic and Research
Foundation, La Jolla, California 92037
Merrill M. Mitler Sleep Disorders Center, Scripps Clinic and Research
Foundation, La Jolla, California 92037
Sidney D. Nau Sleep Disorders and Research Center, Deaconess Hospital,
St. Louis, Missouri 63139
Steven Poceta Sleep Disorders Center, Scripps Clinic and Research Foun
dation, La Jolla, California 92037
Russell Rosenberg Northside Hospital, Atlanta, Georgia 30342
Thomas Roth Sleep Disorders and Research Center, Henry Ford Hospital,
Detroit, Michigan 48202
Arthur J. Spielman Department of Psychology, The City College of the
City University of New York, New York, New York 10031 and Insomnia
'freatment Center, New York, New York 10017
Neil Steinberg Clinical Sleep Services, Santa Rosa, California 95402
Edward J. Stepanski Sleep Disorders and Research Center, Henry Ford
Hospital, Detroit, Michigan 48202
Michael M. Stevenson North Valley Sleep Disorders Center, Mission Hills,
California 91345
James K. Walsh Sleep Disorders and Research Center, Deaconess Hospi
tal, St. Louis, Missouri 63139
Marsha K. Weinstein North Valley Sleep Disorders Center, Mission Hills,
California 91345
James W. Wood Department of Psychology, University of Arizona, Tucson,
Arizona 85721
Vincent P. Zarcone, Jr. Palo Alto VA Medical Center, Palo Alto, California
94304 and Department of Psychiatry, Stanford University School of Medi
cine, Stanford, California 94304
Frank J. Zorick Sleep Disorders and Research Center, Henry Ford Hospi
tal, Detroit, Michigan 48202
Foreword
If ever a book could be called timely, this is it. Sleep disorders medicine has
made rapid advances in recent years. The field has attained growing
respectability, with a textbook recently published, a congressionally man
dated National Commission on Sleep Disorders Research, and a growing
public awareness of the importance of sleep disorders. However, this rapid
growth has made the discrepancy among certain components of the field
all the more obvious. Thus, we find that patients who complain of insom
nia are almost never in the majority of those seen in sleep disorders
centers, in spite of the well-known fact that the prevalence of such individ
uals in our society is by far the largest.
Current articles on insomnia abound, but they tend to be facile
recitations of diagnosis and impractical global recommendations for treat
ment, without providing the essential details. Indeed, the clinical profes
sions really do not know what to do about insomnia. This is reflected in a
number of observations I have made in the recent past. For example, the
majority of individuals who complain of insomnia take alcohol, aspirin,
over-the-counter medications, hot baths, and a host of other nostrums, but
rarely seek a physician. In the unlikely event that a physician is consulted,
he is likely to prescribe a sleep medication but without any particular
consistency, or any clear instructions on its use.
For the most part, patients who have insomnia go to doctors for other
reasons, and even in these cases, no interaction about the problem takes
place. We have carried out studies of clinical practices where we find that
only from 2 to 10 percent of patients may spontaneously present sleep
complaints to their doctors, but when questioned following office visits, 40
to 60 percent of these patients reveal that they have sleep complaints. We
have come to believe that doctors do not want to ask about sleep problems
because they do not know what to do to alleviate them.
In dramatic contrast to the above statement, the authors of this book
do know what to do, and they tell us in clear, precise detail. Hallelujah!
vii
viii FOREWORD
Editor Peter Hauri has pulled together the knowledge and expertise about
insomnia and has made the council of these experts available to patients
and their therapists. Furthermore, much of the clinical experience docu
mented in this book can be available in sleep disorders centers.
Although some feel (quite rightly) that sleep disorders medicine has
come of age, it cannot claim full maturity until clear guidelines for the
effective diagnosis and treatment of insomnia are in place. Whether this
comes about in terms of performing more effectively as a tertiary center or
a consultative service offering expertise and advice to primary care physi
cians, or as a kind of cooperative effort, or whether or not the diagnosis and
treatment can become so efficient that patients should go directly to their
local sleep disorders center, one cannot tell. However, it is absolutely time
to get moving. One could easily estimate, from reading this book, that at
least 75 percent of all chronic insomnia patients can benefit. Formidable
problems remain, but the path is clear, and success, if sleep disorders
specialists are willing to make the effort and follow many of the principles
outlined in this book, is almost guaranteed.
If the population of the earth is over five billion individuals, and if the
various prevalence reports for serious chronic insomnia are reasonably
accurate, perhaps a billion people have insomnia. What a sad thing for life
to be suboptimal for so many people.
Peter J. Hauri has been dedicated to the problem of insomnia since his
days with Allen Rechtschaffen at the University of Chicago, which re
sulted in a doctoral thesis in 1966. He received the prestigious Nathaniel
Kleitman prize for 1989, awarded by the American Sleep Disorders Asso
ciation. Among other things, he was commended for his consistent contri
butions to the problem of insomnia.
I was honored and pleased to be asked to write this foreword,
particularly because I had a chance to read the book perhaps a year or so
before I otherwise would have seen it. I can sincerely say that the authors
have done a great service for sleep specialists and insomniacs the world
over. It is quite true, as Peter J. Hauri says, that much of the good work on
insomnia has not been published. It would be a challenge to bring the
different approaches discussed in this book together in one central place,
but that is a happy challenge, with the likelihood of a favorable outcome.
In the Preface, Dr. Hauri also comments that he hopes the book will go
"beyond a mere 'how-to-do-it' cookbook," but even "how to do it" is of
inestimable value to us all, and just what we do not have currently. I cannot
think of a better example where a huge need has been met so decisively.
William C. Dement, M.D., Ph.D.
Sleep Disorders Center
Stanford University
Palo Alto, California
Preface
There has been a quiet revolution in the treatment of insomnia. Twenty
years ago, insomnia was seen either as a manifestation of depression and
anxiety or as an annoying disorder to be extinguished with hypnotics. In
the late 1960s, I once asked Dr. Jacobson, who developed the progressive
relaxation technique, if he ever used it to treat insomnia. He seemed
annoyed and said, in essence, that insomniacs were a bunch of chronic
complainers that one best kept away from one's practice.
In the 1970s and 1980s, a number of psychologists and psychiatrists
disregarded Jacobson's advice and developed different behavioral and
psychotherapeutic approaches to deal specifically with insomnia. These
strategies were gradually refined and improved until, in a conference on
insomnia at Stanford in December 1988, the consensus was that at least
three of every four chronic insomniacs could be helped quite markedly
with psychological and behavioral treatment techniques.
Unfortunately, much of the good new work that has been done on
insomnia is either not published or published in specialty journals not
available to the general mental health professional. I felt that there was a
need to bring all the different approaches on insomnia together, and I hope
that this book will fill that need. I invited most of the leading insomnia
specialists in the United States to describe their approaches to insomnia,
and I asked them to do this in steps that can be followed by any trained
professional. Most agreed to help with this project.
Although many authors in this book are identified with specific
techniques, in clinical practice, most of us are quite eclectic, tailoring parts
of different techniques to the needs of the individual patient. My main
difficulty as the editor of this book was to keep each author from covering
the entire field of possible treatments of insomnia, to keep the contribu
tions distinct and focused on the specific area in which each author was an
ix