Book Review
Sleep Disorders 
Insomnia: Principles and Management Martin Szuba, Jacqueline Kloss, David Dinges, editors. New York (NY): Cambridge University Press; 2003. 285 p. US$50.00.
Reviewer
rating*: Excellent
Review by: Alan Douglass
Ottawa, Ontario
This book has something to offer all physicians: general practitioners, psychiatrists, and even sleep specialists. The editors and chapter authors form a virtual who’s who of the world’s experts in insomnia research and treatment—Buysse, Kloss, Hauri, Morin, and Mendelson, to name only a few. The introductory foreword by the late Chris Gillin contains a complex patient case history with differential diagnosis. The overriding theme of the book is how deeply the symptom (syndrome?) of insomnia is embedded within other medical diagnoses, especially psychiatric ones. This is not true in the minds of members of the general public, who probably underestimate the gravity of their insomnia.
Particularly surprising in a clinical work of this type is a deep but compact discussion of the neurochemical basis of sleep and wake. An appendix also lists all medications ever used as hypnotics, both over the counter and prescription, showing half-life, advantages, and disadvantages. This part of the book contains valuable clinical wisdom forgotten by many
clinicians: that is, the old standby chloral hydrate is actually trichloroethanol.
The 3 chapters of Part 1 discuss the issue of to which specialty insomnia belongs when at least 50% of cases appear to
be secondary to psychiatric illness. The differing subclassifications of insomnia in the ICD-9, the International Classification of Sleep Disorders, and the DSM-IV are contrasted, as are the results of several large population surveys. Most of the authors agree on the definition of chronic insomnia: a sleep-onset latency of greater than 45 minutes on 5 out of 7 nights weekly for 6 months or longer. Jacqueline Kloss states that “insomnia is the single most common presentation of depression” (p 27) and goes on to note how insomnia may be the earliest sign of depression.
Peter Hauri describes the hyperarousal concept of insomnia. These patients behave as if they were chronically ingesting some activating substance like caffeine when in fact they are not. He also discusses the unusual phenomenon of sleep state misperception wherein some patients have normal, objectively measured, polygraphic sleep but still complain of severe insomnia. He also gives some illustrative case studies and an outline for how to properly take an insomnia history. Charles Morin discusses his cognitive-behavioural therapy for insomnia.
Chapter 6 is a most concise and up-to-date discussion of the sleep–wake role of melatonin. Melatonin is not really a hypnotic but, rather, a circadian rhythm signal. It is useful in jet lag and shift work insomnia, but likely in little else.
Chapter 7 discusses the long-term use of hypnotics, which many physicians prescribe despite the lack of support for this practice from controlled studies or from the Food and Drug Administration. Chapters 8 and 9 discuss the special issues of insomnia diagnosis and treatment in children and older adults, respectively. Nursing home issues are especially well covered.
Chapter 10 discusses the complex issue of circadian rhythm disturbances, including shift work, jet lag, and delayed sleep phase syndrome. This chapter offers many practical suggestions.
Chapters 11 to 13 form a remarkably succinct lesson on the neurochemical control of sleep and waking. It will surprise most readers that adenosine is used as a neurotransmitter in the ventral-lateral preoptic area of the hypothalamus, where it signals the onset of sleep. This nicely explains why adenosine antagonists, such as caffeine, keep us awake. It is also surprising that histamine from the tubero-mamillary nucleus of the hypothalamus sends a prominent wake-promoting signal to cortex that may be responsible for quiet attentiveness, in contrast with the hyperalerting nature of the norepinephrine circuits. This explains why antihistamines produce sleepiness, while modafinil produces nonanxious alertness, compared with the fight-or-flight effect of amphetamines. The effects of lesser known signal molecules, such as interleukin-1, galanin, and TNF-alpha, are also discussed.
This is an ambitious and wide-ranging book that nevertheless hits its many targets. This is a rapidly evolving field. The book should be in the library of every physician who hopes to properly evaluate and treat insomnia.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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