P re f a c e Insomnia
Jack D. Edinger, PhD
It is often said that a little knowledge is a dangerous thing. Well, maybe lacking knowledge is not always dangerous, but the naivete´ accompanying this state can often lead you to underestimate the challenges you actually face. As I look back 31 years when I entered the field of sleep medicine and began to focus my clinical and research efforts on insomnia patients, I recall thinking what a simple and straightforward group of patients they comprised. In fact, I often tell the story that I became intrigued with this patient group after I successfully treated my first insomnia patient following one reading of a chapter written by Richard Bootzin describing stimulus control therapy. I specifically recall how relatively gratifying it was to implement such an easy-toadminister intervention and have the patient show marked improvement in just a few weeks. This experience was so unlike the more haphazard outcomes I observed with other forms of psychological interventions I had tried to that early point in my career. This one experience led me to spend the last 31 years specializing in insomnia treatment and focusing the majority of my research toward the understanding and management this disorder. During my professional voyage over this time period, I have become nothing but truly convinced how naı¨ve my initial view of this patient group really was. Perhaps it is not until one bloodies his or her professional nose that the realization comes as to how complex a chosen field of study actual is. Probably some of my more humbling professional experiences have come in my work focused on the diagnostic classification of insomnia. On the one
hand I can say I have been fortunate to have had opportunities to lead the insomnia classification workgroups for both the second and the third editions of the International Classification of Sleep Disorders (ICSD-2 and ICSD-3). On the other hand I have to admit that such experiences have been eye-opening and in many ways unsettling. In our work on the ICSD-2, we tried to improve the diagnostic criteria sets for the original ICSD insomnia diagnoses and provide more operation definitions for insomnia subtyping. While we were quite proud of our work, we subsequently learned through a large collaborative study that the reliability and validity of many of the insomnia subtypes we carefully tried to define were dismally poor.1 Moreover, by rubbing shoulders with my fellow nosologists, I have learned that what we know about the pathophysiology and subtyping of insomnia pales in comparison to what is known about other types of sleep disorders. And about that first patient I treated 31 years ago.. Well, I ran into him about 6 years ago in one of my clinics and found that not only had his insomnia returned over the years, but he also developed significant comorbid depression and anxiety problems as well. Moreover he had forgotten that I had ever seen him in the past—a humbling experience indeed. It is just that humble and hopefully more enlightened spirit that led me to accept this invitation to serve as guest editor for this sleep insomnia issue of Sleep Medicine Clinics. After all, it wouldn’t hurt to learn a bit more about this topic field and continue to chip away at the nascent naivete´ that seduced me into my career while I was still
Sleep Med Clin 8 (2013) xv–xvi http://dx.doi.org/10.1016/j.jsmc.2013.07.011 1556-407X/13/$ – see front matter Ó 2013 Published by Elsevier Inc.
Preface professionally wet behind the ears. Of course much has been learned about insomnia over the past 301 years but what has been learned has also informed us about how much more there is to learn. In forging this issue, I thought it best to offer readers a bit of a journey through insomnia as a sort of past, present, and future tour of this topic area. Thus, the articles included in this issue provide the reader a fairly thorough historic review of selected areas of insomnia research and also pose new and exciting directions for us to pursue. This issue is divided into two major sections. Section 1, entitled, “Understanding the Nature, Impact, and Etiology of Insomnia,” includes a selection of articles describing the prevalence, morbidity, and potentially important factors related to the pathophysiology and etiology of insomnia disorders. The initial article by Morin and Jarrin provides the reader an up-to-date overview of what is known about the epidemiology of insomnia. The subsequent article by Spiegelhalder and Dieter Riemann provides a review of what is known about the potential role of hyperarousal in insomnia, whereas the article by Vgontzas and Fernandez-Mendoza poses an interesting hypothesis about the role of psychophysiological hyperarousal in the development of a particularly serve insomnia subtype. Finally, the article by Gehrman, Pfeiffenberger, and Byrne provides a cutting-edge update about genetic research on insomnia and where such research may take us. Section 2, entitled, “Challenges and Methods in Insomnia Management,” provides a collection of articles focused on insomnia treatment methods and the challenges posed in managing the range of patient types who present clinically. The initial article by Minkel and Krystal provides an exhaustive review of what is known about the pharmacological management of insomnia patients and highlights areas for future development in this area. The subsequent article by Lovato and Lack discusses the use of bright light therapy in the management of insomnia sufferers with sleep onset and sleep maintenance complaints. The subsequent four articles have been written by groups who are on the frontier of learning how best to management various forms of comorbid insomnia. Specifically, these articles focus on the
management of insomnia occurring comorbid to serious psychiatric illnesses (Soehner, Kaplan, and Harvey), chronic pain (Finan, Buenaver, Coryell, and Smith), cancer (Savard and Savard), and sleep apnea (Ong and Crawford). In the final two articles, the authors describe two rather distinctive approaches to address the challenge of too few providers for too many patients. Specifically, these articles describe methods for disseminating cognitive behavioral insomnia therapy (CBT). The article by Manber, Trockel, Batdorf, Siebern, Taylor, Gimeno, and Karlin describes the largest provider-training program ever devised for the dissemination of CBT within a health care system. Finally, the article by Espie, Hames, and McKinstry provides a very entertaining and provocative description of an animated online intervention program for CBT delivery. For the novice, this issue should provide an updated overview of where we have been and where we hope to go in our understanding and management of insomnia. In contrast, it is hoped that this issue will provide the more seasoned expert new research ideas that help move the field forward. And, for both, it is hoped that this issue will eliminate any naivete´ that leads to underestimating the challenges a true mastery of this topic area poses. Jack D. Edinger, PhD Department of Medicine National Jewish Health Denver, CO, USA Duke University Medical Center Durham, NC, USA E-mail address: [email protected]
REFERENCE 1. Edinger JD, Wyatt JK, Stepanski EJ, et al. Testing the reliability and validity of DSM-IV-TR and ICSD-2 insomnia diagnoses: results of a multi-method/multitrait analysis. Arch Gen Psychiatry 2011;68(10): 992–1002.