Insomniac

  • Gayle Greene
University of California Press, 2008 520 pp., hardcover, $29.95 0520246306 | ISBN: 0-520-24630-6

Insomnia, one of the most common medical problems, chronically affects 10–15% of the adult population. It can be quite disabling, as those who have experienced just one sleepless night can attest. Despite insomnia's frequency and the major impact it has on quality of life, it has traditionally been neglected by the medical and scientific communities, as have most other sleep-wake disorders. As a consequence, the pathophysiology of insomnia remains poorly understood and its clinical management is often quite frustrating.

In Insomniac, Gayle Greene, a professor of literature and a member of the American Academy of Sleep Medicine, provides a tour de force on a broad range of topics related to insomnia. On the basis of her own experiences with insomnia, Greene first approaches insomnia from the point of view of people who are suffering from the disorder. She then contrasts this with the point of view of medical professionals whose job it is to diagnose and treat insomnia.

For example, most patients usually consider insomnia as 'primary'—the cause of the psychiatric symptoms often observed with the condition, such as anxiety, irritability, depression and lack of concentration. Greene supports this hypothesis. Conversely, physicians typically view insomnia as 'secondary'—a symptom or consequence of an underlying medical disorder or, more commonly, a psychiatric disorder. Therefore, primary doctors often prescribe nonspecific, symptomatic treatments or a consultation with a psychiatrist. Greene correctly emphasizes that this therapeutic approach, reflecting the poor consideration that sleep and its disorders have traditionally received from clinicians and scientists, is often incorrect, insufficient or ineffective. She is convinced that, as in other sleep disorders (for example, narcolepsy or restless legs syndrome), a primary brain dysfunction will eventually be found.

Greene then addresses current scientific thinking on the neurobiology of insomnia, with a spotlight on the mechanisms in the brain that are involved with promoting sleep and maintaining wakefulness or arousal. Insomnia could be the result of dysfunction within one or both of these systems. In addition, Greene presents other theories and scientific observations concerning the pathophysiology of insomnia, including those linking it to stress or to increased metabolism.

Given Greene's command of the subject matter, she has clearly been reading extensively on the topic and attending many scientific conferences on sleep. Her firsthand report on the impenetrable, contradictory and fascinating world of scientific meetings is certainly entertaining for noninsiders and may cause the experts portrayed by Greene to reflect on their behavior.

Sleep studies on humans are performed in sleep labs, and Greene gives a detailed account of which questions these tests can—and cannot—answer; for example, sleep studies can confirm the presence of insomnia but can only rarely reveal its cause. Additionally, with healthy distance and wittiness, Greene details the current treatment options for insomnia including both pharmacological and alternative methods.

This book is written with clarity, empathy and knowledge. Carefully collected and updated scientific data are intermingled with experts' opinions and patients' reports. The result is an intriguing journey into the objective and subjective worlds of insomnia and insomniacs, a 'combined view' that makes the book unique. Greene's main intention to give a “voice to insomniacs” has successfully been fulfilled. Beyond this, the book offers a rich and solid account of the concepts of and misconceptions about insomnia and, more generally, sleep disorders and sleep.

Very few errors or omissions can be found in the scientific contents of the book, which are generally well researched and up to date. Some readers will feel that illustrations would have enhanced the clarity of some of the scientific arguments; others will find some chapters too lengthy. This reflects Greene's obvious preference of for telling stories rather than reporting numbers. In addition, the existence of medical, circadian and brain disorders leading to insomnia is too briefly discussed, even though the understanding of these disorders may provide key insights into how to understand and treat insomnia. The thesis that insomnia may often represent a primary disorder (rather then being secondary to medical or psychiatric causes) is favored by Greene but is certainly not universally accepted. Actigraphy as a simple method to assess and document sleep-wake functions—including insomnia—is not even mentioned. Greene is also mistaken about when and where systematic studies in subjects with sleep-wake disorders first began.

In spite of these minor omissions or imprecisions, Insomniac will be of considerable interest for those looking for a comprehensive and well referenced book on insomnia. Both patients and sleep specialists will find information, inspiration and consolation from the unique perspective of an author, an insomnia sufferer herself, who seems to know more about insomnia than do many physicians who care for the people with this disorder.

The world of insomnia and insomniacs is largely unknown and often misunderstood. Greene's book will contribute to filling this gap in knowledge and will hopefully improve the care and empathy for those who suffer from this “terrible disease.”