Treating Sleep Disorders

Sleep disorders are a significant cause of distress in patients of all ages. These patients may seek treatment for such problems from a psychiatrist or family physician. Unfortunately, sleep medicine is not usually included in the curriculum of most medical schools or residencies, so physicians may find themselves at a loss as to how these conditions should be managed. This text presents the fundamentals of sleep architecture and provides descriptions of sleep disorders, their treatments, and effective behavioral interventions. The first chapter is introductory. The physiology of sleep is discussed in Chapter 2, with an emphasis on modalities that measure sleep architecture, duration, and quality. Sleep logging, actigraphy, and polysomnography are described in detail, along with examples of specific sleep disorders and their polysomnographic evaluation. In Chapter 3, the clinical evaluation, polysomnographic analysis, and medical treatment of obstructive sleep apnea (OSA) are discussed. This includes the significant role of obesity and other medical problems that are involved in the disorder. Weight loss, exercise, nasal continuous positive airway pressure (CPAP), and surgery are presented as possible treatments. It is interesting to note that depression and chronic fatigue are major sequelae of OSA. Unfortunately, these symptoms may interfere with treatment. Chapter 4 includes the physiology, clinical symptomatology, and polysomnographic evaluation of periodic limb movements of sleep disorder (PLMS). Its differential diagnosis and medical workup are presented together with pharmacologic interventions. Interestingly, this disorder is also linked to depressionlike symptoms, expanding the medical differential diagnosis of depression. There may be insomnia associated with cognitive-behavioral problems such as catastrophizing and fear of sleep. Chapter 5 provides a thorough description of the clinical diagnostic criteria for narcolepsy. Pharmacologic interventions such as stimulants are discussed, but the behavioral management of the disorder is emphasized. Behavioral treatment is presented as an important adjunct to medication. These interventions include frequent naps, sleep hygiene, dietary measures, and strategies to increase daytime alertness. Chapter 6 is concerned with behavioral interventions for sleep disorders such as narcolepsy, PLMS, and OSA. Although there is some new information in this chapter, there is much repetition of information from previous chapters. Chapter 7 provides an introduction to the chapters that follow. It presents the basics of cognitive science, operant and classical conditioning, self-regulation, and social cognitive theory. This information will be familiar to mental health practitioners but may not be of interest to other readers. The purpose of this chapter is to lay the foundation for the subsequent description of behavioral interventions in sleep disorders. It is pertinent for an understanding of the cognitive problems that perpetuate sleep disorders such as insomnia. The next 5 chapters provide a detailed discussion of insomnia and its differential diagnosis, physiology, and clinical evaluation. The main message of this section is that insomnia may be primary or secondary. The primary type, idiopathic, is associated with any number of psychiatric or medical problems. Secondary insomnia is a result of counterproductive thought processes that prevent the natural occurrence and maintenance of sleep. Phase-advance and phase-delay sleep disorders, caused by primary defects in the diurnal sleep/wake cycle, are described in detail. Medical treatments are discussed, but the main emphasis of this section is on the cognitive-behavioral aspects of insomnia. As a family physician, I found this to be an especially useful chapter. Chapters 13 through 16 discuss pediatric sleep disorders. In my opinion, this section should be required reading for all primary care physicians and psychiatrists who treat children. Common problems, such as frequent nighttime awakenings in infants, bedtime refusal, parasomnias, insomnia, and nocturnal enuresis are addressed, among others. I found the description of sleep from a developmental standpoint very interesting. Behavioral techniques to treat each of the above problems were presented in a lucid and organized fashion. This book is interesting from the perspectives of both family physician and psychiatrist. However, it is not for the casual reader. It is an exhaustively researched text that includes much detail that may not be of general interest. Overall, I found this book impressive and would recommend it highly.