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• W1986482379 abstract "0 n page 909 of this issue, Regestein reports on six cases of highly atypical, serious insomnia that could be treated only with unusual and idiosyncratic drug regimes: One patient showed a response to high doses of phenobarbital, two required diazepam IO or 15 mg, two required hydromorphone 8 or 12 mg, and one showed a response only to’ 300 mg methaqualone, at bedtime. These treatment regimes were arrived at only after most of the more conventional approaches to insomnia had been tried. Their beneficial effects apparently lasted for at least one year, with little obvious habituation or side effects. Regestein’s therapy is contrary to most experts’ advice for the treatment of insomnia. It is commonly believed that the best current hypnotic drugs are benzodiazepines, but that they should be prescribed only in acute insomnia, or, if there is chronic insomnia, only intermittently. Regestein’s approach seems to have worked where this “treatment of choice” had failed. In this way, his report strikes a blow for pragmatic empiricism and one against dogmatic “expert opinion.” It seems high time that we recognize insomnia as a complex phenomenon. In Regestein’s six cases, insomnia appeared to behave more like a primary disease of unknown cause. More often, insomnia is simply a final common pathway, ‘indicating that something else is wrong. It is more like a marker to be investigated further. Most often, anxiety, tension, excessive stress, depression, or neurosis is found at the roots of insomnia, and the benzodiazepines will then mask the basic problem for a few weeks or months. This may be well worth the effort, if the respite that is thus achieved is used to evaluate the more basic psychologic issues. In many other cases, it may be the patient’s lifestyle that is jncompatible with good sleep,‘or faulty learning of sleep hygiene habits, or a reckless disregard for the circadian cycling that regulates sleep and wakefulness. Here, too, hypnotic drugs are often useful stopgap measures, giving the therapist time to teach the codes by which a sane human being gains rest on our planet. In other cases, insomnia may be an index of some underlying medical disease, either one that is present both day and night, such as arthritis or allergy, or one that can only be observed when the patient is sleeping, such as sleep apnea, periodic movements of the legs during sleep, or sleep-related epilepsy. The point here is to remember that insomnia may have multivaried causes. It makes little sense to treat all insomniac patients alike. Regestein reports on a group of highly atypical patients with insomnia who showed responses to medication in idiosyncratic ways. Yet most of us who have worked in this field have accumulated a few such patients; A physician would certaintly be ill advised to treat the majority of insomniac patients with the medication that worked in these specific patients, but it also seems important to know that, with the proper caveats, under rare circumstances, such treatments may occasionally be indicated. Expert advice in Regestein’s cases was wrong because it is based on statistical research, which by definition is focusing on the “average” patient with insomnia (for whom Regestein’s treatment would indeed be wrong). This is, of course, the problem with statistical research: the highly unique, atypical case gets lost in the average and is discarded as “error” variance. This scenario progresses until somebody notices that there is a small subgroup of patients that do not fit into the commonly accepted model. As large a sample of these “misfits” as possible is then typically collected in an effort to find their own “communality.” Regestein’s article goes a long way towards that goal.‘At least it puts clinicians on notice that" @default.
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• W1986482379 date "1987-11-01" @default.
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• W1986482379 title "Specific effects of sedative/hypnotic drugs in the treatment of incapacitating chronic insomnia" @default.
• W1986482379 doi "https://doi.org/10.1016/0002-9343(87)90652-8" @default.
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