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Insomnia
INSOMNIA
MEYER
SOLOMON,
M.D.*
THIS discussion will be limited to insomnia in adults, with special emphasis on ambulatory office patients rather than home-confined, hospital or sanitarium patients. Although etymologically insomnia, or sleeplessness, means lack of sleep from any cause or causes, ordinarily it is used synonymously with hyposomnia or lessening of the duration or depth of sleep, or both, acute or chronic, from any cause or combination of causes, psychologic or nonpsychologic. Since the depth and duration of sleep vary considerably from one individual to another and from one season to another, and since, unless the behavior is such as to attract the attention of or to annoy others, there is often no good objective criterion of insomnia, it is usually, insofar as ambulatory office patients are concerned, a subjective complaint unless supported by confirmatory observation of members of the family or others. The complainant's story and interpretation mayor may not be correct, since it may vary according to his well-being and how much significance he attaches to getting a certain number of hours of sleep of a quality satisfactory to himself. As Klingman,l quoted by Kleitman,2 has so neatly put it: "Those who sleep eight hours and believe that they need ten consider themselves to be suffering just as much from insomnia as others who cannot get more than four or five hours of sleep but who would be satisfied with six or seven." It should be added, nevertheless, that under certain circumstances some persons who get ten hours as their average sleep are not in optimum condition on two hours less. But such decrease in their preferred amount of sleep can usually be corrected by reorganizing their daily routine or conditions of living by establishing an earlier hour of retiring, correcting the physical arrangement in the bedroom, and investigating such causes of morning awakening as noise or light. It is therefore important to check the patient's complaint of insomnia carefully, with full details as given by the patient and, if possible, by others in the home, before accepting at its face value the truth of the general complaint as given by the patient. For example, From the Department of Nervous and Mental Diseases, Northwestern University Medical School, Chicago . .. Associate in Nervous and Mental Diseases, Northwestern University Medical School; Chairman, Department of Neuropsychiatry, Mount Sinai Hospital. 178
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a patient complained to me that, among other annoyances, she had suffered from poor sleep for two years past. On careful inquiry it was learned that this .amounted to nothing more than partially awakening in the middle of the night for a few minutes or so and immediately dropping off to sleep again and sleeping soundly until about 8 o'clock in the morning. Furthermore, she had lost no weight and had none of the other clinical effects of real sleeplessness over a two year period. CLASSIFICATION OF INSOMNIA
Insomnia is unquestionably one of the most common complaints in medical practice. Although there are many classifications of the condition, such as age, degree of completeness, clinical diagnosis, and whether acute or chronic, I shall refer here in particular to classification according to cause and to time of incidence. Based on the tim.e of incidence there are three types of insomnia: (1) Difficulty or delay in falling asleep, known as initial or predormitional insomnia. This is the most common type and results especially from habit, fear, worry and anxiety states, with the ability to sleep late in the morning. Laird7 goes so far as to claim that it occurs in three fourths of the population. (2) Intermittent, broken, restless sleep, which varies almost directly with age, and Laird7 believes that it occurs in about 40 per cent of adult men. This type of insomnia is commonly associated with unpleasant dreams and nightmares, and in middle-aged persons is frequently accompanied by digestive disturbances. (3) Early morning awakening, so-called terminal insomnia, with difficulty in returning to sleep. This is normal with advancing age, is common in arteriosclerosis and hypertension and, I agree with Pollock, 8 Muncie9 and many others, is especially present in mental depression. It has been found that most people wake up spontaneously during the second half of the night but fall asleep again, and that when one has had "enough" sleep, one awakens more and more frequently and finds it more and more difficult to fall asleep again until finally one remains awake. 2 When this final stage is reached by 3 or 4 or 5 o'clock in the morning instead of the usual hour of awakening (6 or 7 or 8 o'clock or so), the condition is called terminal insomnia. When this oc~urs in elderly persons, who ordinarily need less sleep than formerly but who go to bed at the usual if not an earlier hour and are worried if they do not sleep to as late an hour as previously or as late as younger people do, one need have no concern. Also, it is not merely a question of how early one awakens but how early one re-
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tires, how many hours of sleep one has had and how light or heavy a daily program one follows. Combinations of the above three types of insomnia may occur. Occasionally there is a reversal of the sleep rhythm with wakefulness by night and sleep by day, as in some cases of epidemic encephalitis and in cerebral arteriosclerosis with other manifestations of senility. CAUSES OF INSOMNIA
Insomnia is a symptom of some underlying cause or causes. There are three main groups of causes, as follows: (1) Purely external, such as extremes of heat or cold, light (especially early morning sun), noise (especially early morning traffic), uncomfortable bedding, crowding, and so forth. (2) Physical diseases and toxic causes. This covers a large number of conditions, including pain or severe discomfort from injury or disease of any kind; organic disease not especially accompanied by pain, as in tuberculosis, arteriosclerosis, thyrotoxicosis, heart disease and hypertension, organic brain disease, tinnitus aurium; or posttraumatic, or from arthritis, neuritis and the like; cerebral excitement from endogenous toxic states such as infection or uremia, as well as from exogenous toxins such as the excessive use of coffee, tea or alcohol especially in the latter part of the day; gastro-intestinal disturbances with discomfort from dyspepsia, indiscretions in diet, hunger, hypoglycemia, and so forth. (3) Psychological causes. These are the most common causes of insomnia and comprise the whole range of mental and emotional factors, the psychoneuroses (fatigue or neurasthenic, anxiety, hysterical and obsessive-compulsive states) and psychoses (especially depressed, excited, confusional and schizophrenic states), worry about and especially fear of insomnia, of the possibly serious effects of sleeplessness, of insanity and of incurability. Insomnia which is not traceable to physical disease or to some definite physiological or external origin, is most apt to be associated with anxiety about something and it is our job to find out just what that something is. It is clear that insomnia is always a definite indication that something about the patient needs investigation since it may be the end product of a multitude of possible causes and, like cough or pain or dyspnea, is only a symptom. Difficulty in sleeping dependent upon residual excitement from the day is not uncommon in sensitive, excitable, worried individuals. Some such individuals have a certain degree of recurrent insomnia of many years' duration. Psychogenic insomnia with sleeplessness as the only complaint at
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the original consultation is often complex and requires careful study, diagnosis and management. In other instances it is simple in origin and management from the very beginning. It will not be possible to discuss the characteristics and treatment of insomnia in special clinical conditions such as delirious, excited and similar states. This aspect will be found in the various clinical texts on psychiatry or psychological medicine. CLINICAL EFFECTS OF LOSS OF SLEEP
For an authoritative discussion of sleep which, unfortunately, I have no space to present, I urge you to consult the very splendid book by Kleitman 2 on Sleep and Wakefulness. He conducted experiments on partial deprivation of sleep with continued muscular activity so that the effects were due partly to lack of sleep and partly to muscular fatigue. In his standard procedure there was a waking period of sixty-two to sixty-five hours of staying awake until late in the evening of the third day of sleeplessness. He himself remained awake on various occasions to 100 hours and with the aid of benzedrine sulfate as long as 180 hours. He found, in general, no deviations from the normal range in the vegetative functions (heart rate, blood pressure, body temperature, basal metabolism, appetite, composition of the blood and urine), while the red blood cells and hemoglobin percentage showed variable results but with no general tendency to oligocythemia. In studying the effects on the nervous system, Kleitman employed two classes of tests with the following results: (1) Tests in which effort is not a determining factor (knee jerks, pupillary light response, cutaneous sensibility to faradic current, touch and pain, visual acuity, brain potentials, electrical skin resistance) showed, as with vegetative functions, no consistent variation for the group as a whole for all tests but one, namely, sensitiveness to pain, with cutaneous sensitivity to touch unchanged but to pain a progressive increase (lower threshholds). (2) Tests in which effort is a determining factor showed in general a decreased performance ability during the period of sleeplessness. Although mental and muscular performance in various tests can be maintained at normal levels if the tests are of short duration, sustained effort is impossible. The most outstanding and significant findings in all studies on lack of sleep were found to be increased sensitivity to pain, impairment of the disposition with hyperirritability and irascibility, a tendency to day-dreaming, hallucinations and other similar signs. All of these point to fatigue of higher levels of the cerebral cortex, which are in constant operation during the period of
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wakefulness and are responsible for the critical analysis of incoming impulses and the establishment of adequate responses in the light of the person's or animal's experience. Kleitman found in humans itching or slight burning sensitiveness of the eyelids, and mild mannered persons became ill tempered under continued efforts to keep them awake. Thus, the sleepy individual can make a short lasting effort but cannot sustain it. Many experiments have shown that animals die from lack of sleep:3 Menaceine's puppies after four to six days; Tarozzi's three dogs after nine, thirteen and seventeen days; although Pieron's twenty dogs were alive after from 30 to 505 hours and Okazaki's after fourteen to seventy-seven days, of Kleitman's twelve puppies kept awake from two to seven days two died without awakening after being permitted to sleep. In experimental animals which died or were killed after a period of insomnia, various brain and other nervous system changes have been reported. Kleitman concludes: 4 "From observations made on persons undergoing experimental insomnia it can be stated with assurance that no immediate untoward developments need be feared from the loss of a night's sleep, whether it be partial or complete. Prolonged, continuous wakefulness, however, even if undergone voluntarily, may cause temporary mental deterioration." Insomnia in clinical practice is a more complicated matter. Here the patient is worried about his sleeplesness; he knows that it is not voluntary or merely experimental, and it may continue not merely for days but for weeks and months. Varying with the cause, we commonly note increased fatigue, lack of concentration, deficiencies of memory, inability to perform effective mental work, impairment of muscular coordination (especially for more delicate movements), anorexia, irritability of temper, loss of weight, head and bodily paresthesias, restless and agitated pacing of the floor, and general physical and mental instabiIity.lO Weight loss, especially in depressed patients, due to insomnia, anorexia and other factors, may be as much as 20 to 50 pounds. Craig l l is right when he says: "Some persons are much more intolerant of deficient sleep than are others; indeed, some individuals will become definitely insane within a few days if sleep is not obtained." Popov5 reports such a case, with complete recovery after the patient was allowed to sleep. I also agree with Minogue12 of Australia who found that insomnia from whatever cause led to rapid mental and physical exhaustion, usually with headaches, especially a "tight band around the head" as
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if "the head were bursting." If long continued, the patients become desperate, restless, apprehensive; many are haunted by the fear of insanity; some may later become suicidal, especially if living alone, with no relatives or friends to console them, if too religious or if elderly. Minogue quite correctly concludes: "Suicide is the end result of a large number of factors, both physical and psychological. Whatever its cause, it is generally preceded by a period of insomnia with its concomitant symptoms and signs. It is imperative for us to realize the risk of suicide in such patients and also that the patient requires urgent and immediate treatment. If appropriate treatment is given, I am convinced that many a suicide can be prevented, a fact well known to all psychiatrists. But unless we, as a profession, realize that sleepless, depressed and worried patients are prone to suicide, and that such patients can be very successfully treated by modern psychiatric methods, there seems to be little hope of appreciably reducing the suicide rate in Australia." What is true of Australia is likewise true of the United States. In considering the dangers of real insomnia, one must appreciate the possibility of a vicious circle with insomnia aggravating the nervous and mental condition, and vice versa. I have summarized 13 the situation briefly in a previous discussion in the following words: "It is not merely the direct results of lack of sleep but its indirect and psychological results which are of serious import. The patient's hours of wakefulness at night, with everyone else sleeping and all quiet~ may seem to him very much longer than they in fact are. It is also during such periods at night that his rushing thoughts, emotionalism, anxiety, worries and fears take possession of him in more unrestrained fashion. Then come his worries over the real or imagined dangers of insomnia. Being more unstable because of insomnia, he is inclined the following day to be more in the grip of his anxieties and fears. His worry about the lack of sleep leads to an excessive interest in whether or not he will sleep well. He may have actual despair from his sleeplessness. Fear of the night, of insomnia and of bed time may become perdominant. Fear of insanity may result from insomnia primarily or be exaggerated by it. Although insomnia is only one cause of the fear of insomnia in psychoneurotics (and psychotics) it is ~n important cause. Continued sleeplessness may lead to a feeling of lack of self-confidence and self-control." In all cases of persistent, prolonged insomnia the patient should be studied carefully to determine whether or not a real mental depression is not the actual clinical condition present, and, if so, it should be treated as sm:h, with, if ~evere enoug-h ami indicated, hospitaliza-
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tion and so-called electroshock therapy; in selected cases estrogen therapy15. 16 in the female and androgen therapy17 in the male have apparently been of value in true involutional melancholia. GENERAL MANAGEMENT OF INSOMNIA
In all cases a careful sequential history of the onset and development to date is essential. This should include its degree, duration, effects, probable cause of onset, factors responsible for its continuation, and the patient's attitude toward his condition. His other complaints should be gone into sufficiently fully. Review the patient's daily program-his time of arising, routine of the day, hour of retiring, the amount and character of his sleep before and since the onset of his . . msomrua. A personality estimate and determination of the mental condition. with decision as to the existence or absence of a psychoneurosis or psychosis and the approximate clinical diagnosis can usually be made during the first extended consultation. Take the complaint of insomnia as seriously as you do (or should) any other symptom. At the outset a full physical examination should be made with definite exclusion of obvious causes (such as pain, dyspnea, pruritus), diseases of the gastrointestinal, circulatory, respiratory or excretory systems, hypertension, organic neurologic diseases and alcoholic toxic states. Whatever laboratory tests are really necessary should not be omitted. By this time you should have a more definite opinion concerning the patient and his complaint. Each case is an individual affair. No fixed rules can be laid down. Unless the patient is willing to put himself under your care, to see you frequently enough and to permit proper study and supervision, it is better to give merely general advice, outline the situation and not prescribe hypnotics except for two or three nights and then not to be refilled. Explain your reasons to the patient. All psychoneurotic patients with insomnia, except of the sligHtest degree, are much better sleeping alone. All clocks are generally best removed. A dark, quiet, properly ventilated room is desirable. Each individual has his favorite, preferred choice of bedspring, mattress, bedding, pillow arrangement, ventilation and posture in bed. If . there is increased blood pressure, have the patient try using no pillow. If there is sensitiveness to cold, a warm bed-even with hot water bottles-is in order. If cold feet while in bed are a source of discomfort, help may be found in a hot foot bath at bedtime, or hot water
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bag to the feet, being sure to avoid burns, or the patient may wear woolen socks to bed. If the patient is hungry at bedtime, milk or warm soup with crackers a half hour before retiring should be soporific. If awakening occurs from hunger, a glass of milk and crackers may be taken at the time of awakening. If there is overuse of coffee, tea or alcohol, reduce the amount consumed during the latter part of the day or after lunch, especially at or near bedtime. The effect of coffee and tea varies from one person to another. If there is flatulent distention of the stomach or intestines, try onehalf glass of water with 10 to 15 grains (0.65 to 1 gm.) of sodium bicarbonate at bedtime. For disturbing symptoms in medical or surgical conditions, such as cough or dyspnea, relief as necessary is in order. Some patients are helped, others made worse, by a glass of hot whiskey or water, by reading, or by attempts at muscle relaxation at bedtime. Gentle massage, especially of the spinal muscles, just before the usual sleeping time is apt to be valuable, especially in neurasthenics and bed patients. To exclude the early morning light, opaque window shades (dark green shades instead of or in addition to yellow, tan or white ones) should be drawn low at bedtime. For sleeping by day, the use of an opaque screen about two feet from the window is helpful. A void having the light fall directly on the head. Sedative hydrotherapy may be employed in several ways: as prolonged (one quarter to one-half hour) warm (96 0 F.) bath; cold wet pack for three-quarters to one hour; or, in excited states, neutral tub baths for two or three hours or continuously, especially with an ice cap to the head. The last is always, and the second is usually, a hospital procedure. Suggestion, assurance, diversion, distraction, release of anxiety and tension are occasionally of service as conditioning processes to induce sleep: drinking or eating or even a warm bath; muscular relaxation; various psychological procedures such as listening to one's breathing, prayer, autosuggestion of Coue, naming categories following the alphabet, and so on. If sleeplessness follows a period of unusually concentrated or prolong~d mental work, a short vacation with plenty of rest and sleep should be advised, often at the onset, with the addition of mild hypnotic medication. T know that many of the above suggestions cannot be carried out in certain patients owing to limitations of living quarters, hours of
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employment and financial situation, but no symptom demands such varied therapeutics. As Kleitman6 concludes: "Insomnia, in the sense of hyposomnia, is nearly always traceable to some disturbing factor, capable of keeping the cortical centers, or the wakefulness center in the hypothalamus, directly in a state of prolonged activity. The therapeutics of insomnia consist in the removal of the disturbing factors and, if that fails, in the use of depressing drugs." In the majority of cases no physical cause can be found for the insomnia and the patient needs a combination of a common sense exploration of his mental and emotional problems with psychological management, a survey of his daily program of activity, and the rational use of hypnotic drugs. PSYCHOLOGICAL ASPECTS AND PSYCHOTHERAPY
In considering psychogenic insomnia, emotional conflict is so important that its consideration is really an introduction to the problem of psychoneuroses and so-called functional psychoses. Thus, the management of the patient goes step by step with the treatment of the symptom of sleeplessness. This means an investigation of the patient's personal problems, his state of health, his daily program, domestic (marital and family), financial, occupational, social, recreational, sexual, religious, and ethical-moral adjustments. The attitude of the physician must very definitely be one which inspires confidence. The physician must have and show confidence in his own ability to help the patient recover and in the patient's ability to regain his equilibrium. In the treatment of a disease associated with insomnia, one must remember that in continued pain with prolonged insomnia, especially in unstable individuals, eventual psychoneurosis or even psychosis may result. In like manner organic disease of any sort may clear up and insomnia continue. Discuss the past anxieties which led to or the present anxieties which maintain the insomnia. With time, interest, sympathy, patience and understanding in the very first interview or the first few interviews, the patient will confess his anxieties, medical and nonmedical. SOme can, others cannot, be settled by discussion. If you cannot remove the anxiety responsible for the sleeplessness, at least reassure the patient as much as possible. Use explanation, suggestion and readjustment of his daily program, attitudes and ambitions, as the case may be. If intensive personality study is indicated, I do not favor adhering to anyone school of psychological thought, Freudian or otherwise,
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but study each patient individually, letting the quips fall where they may. I do not find any real basis to the current systems of dream interpretation and their supposed invariable importance and value in unearthing the causes of the disorder. Hypnosis is ordinarily of no, little or temporary value and it may not be possible to use it in sleeplessness in office patients. PHARMACOTHERAPY: THE USE OF HYPNOTIC DRUGS
Owing to space limitation I shall confine my discussion to the pros and cons of using hypnotics in general and to technic and precautions in their use. The chemistry, characteristics, dosage and methods of administration of the various drugs can be found elsewhere, as in the presentations by Weiss,18 Feiling,19 Fantus,20 Winans,21 Dercum,22 Diethelm,23 ROSS,24 Crichton-Miller 25 and Grabfield. 26 For special attention to the barbituric acid group I refer you to Weiss18 and the special report of the Journal of the American Medical Association. 27 Goodman and Gilman 28 give a comprehensive discussion. The Case For and Against the Use of Hypnotics.-Sleeplessness due to pain and other discomfort requires necessary symptomatic relief, even morphine or codeine. Hyoscine is used exclusively in selected cases in psychiatric hospital practice. Bromides are rarely effective in insomnia of real consequence. Chloral and paraldehyde, not used as frequently now as formerly, are in my opinion for hospital and sanitarium rather than home use in ambulatory office patients. By hypnotics I refer more particularly to the drugs of the barbituric acid group such as barbital, veronal, medinal, sodium amytal, ipral, nembutal, seconal, "delvinal" sodium and many others, and much less to the so-called sedative group, bromides, chloral, paraldehyde), but not at all to the so-called euphorotics (alcohol, opium, morphine, heroin, cocaine). I agree with others that with a change of dosage a so-called sedative may produce hypnosis or narcosis. Surely there can be no scientific objection to the desirability or necessity of medication for actually disturbing symptoms of emotional origin, as for instance the temporary use of hypnotics for psychogenic insomnia while the patient is being studied and treated causatively. And yet there is a surprising disagreement in attitude and policy on this important clinical problem. This is especially so in the case of insomnia accompanying the psychoneuroses. As p3 have said elsewhere, among the large number of psychotherapists and psychopathologists who are in direct opposition or do not openly advocate or even mention the occasional necessary use of hypnotics in the treat-
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ment of insomnia in the psychoneuroses, I found such names as Dubois, lanet, Freud, lung, Adler, McDougall, Prince, Dejerine and Gauckler. Yet we find that Dejerine and Gauckler29 admit that the patient with insomnia of phobic origin often clings to his fear of insomnia so strongly that the bad habits which he has formed are frequently kept up in spite of all psychotherapeutic efforts. As a consequence of the many arguments against the use of hypnotics by men of the highest standing in psychopathology, and of newspaper items emphasizing the dangers of habit formation or referring to their employment for suicidal purposes, many physicians fear or apologize for prescribing hypnotics under any circumstances. This in my opinion is illogical, unscientific and unfair to patients, the medical profession and the public in general. The main arguments against their use, and answers to these arguments, have been given by me14 elsewhere and are herewith summarized: 1. The use of hypnotics is not causal treatment, but palliative; however, symptomatic treatment is employed elsewhere in medicine. 2. There is danger of toxic effects; but their avoidance, as with other drugs, is merely a question of technic and precautions. 3. Self-medication may ensue; but with proper precautions this should not result. 4. Their use is a temporary and not permanent help or solution; hut this applies to all palliative therapy. 5. It is a resort to an artificial crutch; but so are many other procedures in practice. 6. It is a line of least resistance; but it need not be so abused. 7. Other necessary treatment may be neglected by physician and/or patient; but it should not be. 8. It gives the patient the wrong idea of the causes and of the fundamental importance of the psychotherapeutic aid required; hut it does not if properly handled. 9. There is danger of drug addiction. 10. The drug ordered may be used for suicidal purposes. The last two arguments will be answered immediately: I fully endorse the views of Craig9 who spoke from much experience when he said: "As a profession we are unduly timid of giving hypnotics and in consequence the public, as a whole, objects to them. Brought up as I was in the same attitude, long experience has taught me the folly of such an outlook. The chief objection, I gather, is the fear of inducing a habit. Once more experience has taught me to be much more afraid of the effects of sleeplessness than of any danger of producing an addiction, a danger which is almost negligible. Let those persons who
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are constantly talking about addiction produce the evidence upon which they base their statements." Although the suicidal use of the drug ordered is apt to occur in the psychoses and alcoholism, precautions in the method of prescribing should prevent this. Suicidally inclined patients, not psychoneurotic, have many sources (newspaper items and drug stores) of information concerning hypnotics. Suicidal use is especially apt to take place in worried depressions. But an important aggravant of this possibility is the unrelieved, prolonged, marked insomnia present in such psychotic states. Psychoneurotic patients are notoriously not inclined to suicide. Too many physicians make the mistake of misdiagnosing real mental depressions, even of the worried or agitated type, as psychoneuroses, and in such depressions the need of sufficient sleep is absolutely essential and fundamentally basic in treatment. In fact, practically all truly depressed patients with insomnia are in need of the aid of hypnotic medication since they are especially resistant to all methods of psychotherapy. Such depressed patients should, if their condition is pronounced enough, be hospitalized, hypnotics used as required, necessary precautions against suicide observed, and so-called electroshock therapy instituted when indicated. Furthermore, prolonged, severe insomnia may lead to depression and suicidal thoughts and attempts. One of the common characteristics of depression, if not slight or mild, as in excited and other states, is the inability to secure a sufficient amount of sleep with moderate doses of hypnotics. Craig9 was certainly fully justified when he insisted that "As with every other disorder, the sooner we treat sleeplessness the morc quickly we shall be able to correct it, and, what is most important of all, sleeplessness quickly relieved leaves no terrors behind it compared with prolonged insomnia. The physicians who are most likely to produce a drug habit are those who have permitted their patients to become terrified by the experience through which they have passed. "In the case of hypnotics for insomnia, it is generally true that it is not the drug but the lack of confidence in the ability to sleep without it which may become a habit, with the result that they are reluctant to break away from the means which have afforded them relief." It is our duty to see to it that patients are satisfied and relieved if at all possible by nondangerous methods adapted to the particular case. Our personal preferences should not be made rigid practices. We surely are not justified in dismissing patients suffering from insomnia by merely telling them that it does not matter whether they
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sleep or not, or that they will sleep if they will not worry about it, or to forget it. Even if he is exaggerating his degree of insomnia, the patient must be satisfied that he is sleeping soundly and sufficiently; the general condition of the patient should always be the real guide. If the patient is in a condition in which he cannot be satisfied by explanation or by other measures, hypnotics should be temporarily used. If you can easily and quickly produce sleep, you have a much better chance of getting a psychological hold on the patient and of increasing his confidence in himself. A period of sleep promptly given helps rapidly to break up the habit of sleeplessness, to diminish or to eliminate the other bad physical and psychological effects of insufficient sleep, and to put the patient in a psychological condition more suspectible to psychotherapy and physiotherapy. At the same time, fear of the medication given him which is so often present and deep rooted should be removed. As a matter of truth, if hypnotics are not used for insomnia, one can never be sure that other measures will produce sleep. Therefore, without the employment of hypnotics, one cannot give any definite promise of sleep on any particular night. But with medication one is fortified and can assure the patient that with a sufficient dosage and with one or the other of the hypnotics or some combination of them, sleep can positively be obtained. Furthermore, if you continue to assure a patient that he will sleep without hypnotics but his sleeplessness continues, you are gradually losing the confidence of your patient. In fact, as ROSS30 says, it is certain one can be just as unscientific in withholding hypnotics as in giving them when it is not indicated. Technic and Precautions in Using Hypnotics.-I shall here enumerate many practical "do's and don'ts." Deal with your patient insofar as possible on the principle of "open covenants openly arrived at." Explain to the patient that you are using hypnotics temporarily, that you will study and treat his general condition and that hypnotics will be gradually omitted. As many patients fear the use of hypnotics, after explaining your plan to the patient, get his views and attitude. Assure him that if he takes only what medication you order and remains under your medical supervision and sees you as frequently as you wish, he need fear neither the "dope habit" nor toxic effects. If occasionally the patient at first prefers not to take hypnotics temporarily even when so requested by you, he will generally agree to do so after he gains more confidence in you.
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All prescriptions for hypnotics or sedatives should have a "non repetatur" or "Do not refill" order. Do not prescribe hypnotic tablets or capsules by the bottle. Order only enough to last until the next visit. Do not tell the patient to take hypnotics as he needs or wishes. And do not have him renew his prescription on his own initiative or renew the prescription for hypnotics routinely by telephone. Such methods lead to self-medication with its possible dangers. If the patient is suicidal, and this can usually be determined at the first visit, do not give the prescription or medication directly to him but to someone else (relative, nurse) who will have control of it. Such suicidal patients, of course, really need hospitalization. Do not promise positive sleep the first night but promise that sufficient sleep can be obtained shortly with proper dosage and combination of hypnotics. Give a large enough dose at once to insure sleep, if possible, the very first night of treatment. Explain in advance some of the possible undesirable results (such as drunken feeling) the morning after taking the drug and until the dose is adjusted. After a sufficient number of good nights of sleep the usual patient readily agrees to gradual reduction of dosage until it can be omitted altogether. Sometimes at this stage, if he prefers, one dose of the drug can be ,laced within reach of the patient to be used, if he wishes or really needs it, without rising. This may give him the degree of assurance which will lead to peaceful sleep. In 6~ce practice it is best not to continue using hypnotics for more than two to three weeks or so without attempting to reduce the dose gradually. The hypnotic should preferably be varied as the patient improves or fails. to get results. If petmanent relief depends upon a knowledge of the cause of the insomnia and the patient refuses to cooperate in finding out the cause, one may refuse to give hypnotics until he changes his attitude. A supply for only two or three days at a time should be ordered as a rule. In selected cases during the convalescent phase this may be somewhat extended. It 'is well to have at least a telephone report daily for the first few days, See the patient, if at all possible, at least two or three times a week in the first week; the frequency thereafter varies with each case. If the patient callnot be seeq frequently enoug-h to check up on th~
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progress, the diagnosis, possible toxic effects, the advisability of increasing or decreasing the dose or best time of administration or of changing the medication, refuse further to treat the patient or to assume any responsibility. In the case of the average office patient I give the prescription directly to the patient or relative without fear of misuse since I have examined the patient sufficiently, have arrived at a tentative diagnosis, have made reasonably sure that he is not suicidal, have given an explanation and the plan of procedure and have had an understanding with the patient. This does not apply to depressed patients, especially if more than slightly depressed, and particularly if suspected of being suicidal, in which case, unless hospitalization seems definitely indicated, the hypnotic is under the control of someone else in the home. If preferred, you may dispense the hypnotic yourself or have special arrangements with the druggist to give the hypnotic without the patient knowing its name. It is much better to know a few selected hypnotics well than to know too many too little. Use hypnotics judiciously combined with causal therapy, including psychotherapy plus any palliative physiotherapy advisable. When, from the history and condition of the patient, real help is needed for obtaining essential sleep, hypnotics should be used not merely as a last resort and half-heartedly but promptly from the very first visit and wholeheartedly-with the practical suggestions as to technic and precautions enumerated above. SO·CALLED ELECTROSHOCK AND INSULIN SHOCK THERAPY IN PSYCHOSES WITH INSOMNIA
Where insomnia is part of a psychosis, we find that, as the psychosis is improving, sleep without medication is one of the earliest signs of such improvement. This applies to the use of so-called insulin shock and electroshock treatment, which has almost universally displaced metrazol. In depressions, including agitated depressions, in which pronounced and prolonged insomnia is common, so-called electroshock treatment produces remarkable results in a large proportion of patients, with a clearing up of the sleeplessness in many cases in a truly unbelievable manner. The patient soon gets along without drugs. It cannot be too often emphasized that many cases of depression are wrongly diagnosed psychoneurosis and so improperly treated. Although mild depressions may be treated on an ambulatory, homeoffice, extramural basis, others, especially the more pronounced and
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more particularly the agitated types with marked insomnia and SUIcidal thoughts or tendencies, need immediate hospitalization. Schizophrenic patients, especially early, may be greatly helped or may recover by so-called electroshock and/or insulin shock therapy plus psychological management. BIBLIOGRAPHY 1. Kingman, R.: The Insomniac. New York M. J. & Rec., 129:683.c687; 130:17-
21, 1929. 2. Kleitman, Nathaniel: Sleep and Wakefulness, as Alternating Phases in the Cycle of Existence. Chicago, University of Chicago Press, 1939. 3. Ibid., Chapter 21, Experimental Deprivation of Sleep. 4. Ibid., Chapter 27, Insomnia or Hyposomnia, p. 381. S. Ibid., p. 381. 0. Ibid., p. 527. 7. Laird, Donald A.: Cyclopedia of Medicine and Surgery. Philadelphia, F. A. Davis Co., 1934, Chap. 11, pp. 307-313. 8. Pollock, L. J.: Disorders of Sleep. M. CLIN. NORTII AMERICA, 13:1111, 1930. 9. Muncie, Wendell: Insomnia in Clinic Psychiatric Practice. Johns Hopkins Hosp. Bull., 55:131-153 (Aug.) 1934. 10. Worster-Drough, c.: Insomnia in Early Mental Disease. The Lancet Extra Numbers No. 2, London, Wakley & Son, Chap. 7, pp. 37-41. I I. Craig, Maurice: The Early Treatment of Mental Disorder in Early Mental Disease. The Lancet Extra Numbers No. 2, London, Wakley & Son, Chap. 41, pp. 191-194. 12. Minogue, M. J.: Symptoms (Insomnia) Preceding Suicide. M. J. Australia, 2: 598.c600 (Oct. 31) 1936. 13. Solomon, Meyer: Shall Hypnotics Be Used in the Treatment of Insomnia in the Psychoneurosis. M. J. & Rec., 138:22-26 (July 5) 1933. 14. Ibid., pp. 22-25. 15. Danziger, Lewis: Specific Treatment of Psychosis Due to Estrogen Deficiency. Arch. Neur. & Psychiat., 51.:462-468 (May) 1944. 16. Darken, Marjorie A. and Burlingame, C. Charles: Evaluation of Laboratory Controlled Estrogenic Therapy in the Psychoses. Dis. Nerv. System, Vol. 5, No. 7, July, 1944. 17. Danziger, Lewis, Schroeder, Harold T. and Unger, Arthur A.: Androgen Therapy for Involutional Melancholia. Arch. Neur. & Psychiat., 51:437461 (May) 1944. 18. Weiss, Soma: Indications and Dangers of Sedatives and Hypnotics, with Special Reference to the Barbituric Acid Derivatives. Internat. Clinics, pp. 38-66 (March) 1936. 19. Feiling, A.: Insomnia (Use of Hypnotics). Practitioner, 129:130--139 (July) 1932. 20. Fantus, B.: Therapy of Insomnia at Cook County Hospital. J.A.M.A., 102: . 1846-1848 (June 2) 1934. 21. Winans, H. M.: Insomnia. Internat. Clin., 1:39-55 (March) 1935. 22. Dercum, Francis X.: Rest, Suggestion and other Therapeutic Measures in Nervous and Mental Diseases, 2nd ed. Philadelphia, P. Blakiston's Son & Co., 1917. 23. Diethelm, Oskar: Treatment in Psychiatry. New York, The Macmillan Co., 1936. 24. Ross, T. A.: Insomnia. Practitioner, 144:329-336 (April) 1940.
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25. Crichton-Miller, H.: Insomnia: An Outline for the Practitioner. E. Arnold & Co., London, 1930. 26. Grabfield,G. P.: Treatment of Insomnia. M. CLIN. NORTH AMERICA, 19: 1597-1601 (March) 1936. 27. Barbituric Acid and Derivatives. Several contributors. Pamphlet published by American Medical Association. 28. Goodman, Louis and Gilman, Alfred: Pharmacologic Basis of Therapeutics, Chaps. 9, 10, 11 and 12. New York, The Macmillan Co., 1941. 29. Dejerine, J. and Gauckler, E.: The Psychoneuroses and Their Treatment by Psychotherapy. Authorized translation by Smith Ely Jelliffe. Philadelphia, J. B. Lippincott Co., 1913, p. 364. 30. Ross, T. A.: The Common Neuroses. London, Edward Arnold & Co., 1923, p.95.
MEYER
SOLOMON,
M.D.*
THIS discussion will be limited to insomnia in adults, with special emphasis on ambulatory office patients rather than home-confined, hospital or sanitarium patients. Although etymologically insomnia, or sleeplessness, means lack of sleep from any cause or causes, ordinarily it is used synonymously with hyposomnia or lessening of the duration or depth of sleep, or both, acute or chronic, from any cause or combination of causes, psychologic or nonpsychologic. Since the depth and duration of sleep vary considerably from one individual to another and from one season to another, and since, unless the behavior is such as to attract the attention of or to annoy others, there is often no good objective criterion of insomnia, it is usually, insofar as ambulatory office patients are concerned, a subjective complaint unless supported by confirmatory observation of members of the family or others. The complainant's story and interpretation mayor may not be correct, since it may vary according to his well-being and how much significance he attaches to getting a certain number of hours of sleep of a quality satisfactory to himself. As Klingman,l quoted by Kleitman,2 has so neatly put it: "Those who sleep eight hours and believe that they need ten consider themselves to be suffering just as much from insomnia as others who cannot get more than four or five hours of sleep but who would be satisfied with six or seven." It should be added, nevertheless, that under certain circumstances some persons who get ten hours as their average sleep are not in optimum condition on two hours less. But such decrease in their preferred amount of sleep can usually be corrected by reorganizing their daily routine or conditions of living by establishing an earlier hour of retiring, correcting the physical arrangement in the bedroom, and investigating such causes of morning awakening as noise or light. It is therefore important to check the patient's complaint of insomnia carefully, with full details as given by the patient and, if possible, by others in the home, before accepting at its face value the truth of the general complaint as given by the patient. For example, From the Department of Nervous and Mental Diseases, Northwestern University Medical School, Chicago . .. Associate in Nervous and Mental Diseases, Northwestern University Medical School; Chairman, Department of Neuropsychiatry, Mount Sinai Hospital. 178
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a patient complained to me that, among other annoyances, she had suffered from poor sleep for two years past. On careful inquiry it was learned that this .amounted to nothing more than partially awakening in the middle of the night for a few minutes or so and immediately dropping off to sleep again and sleeping soundly until about 8 o'clock in the morning. Furthermore, she had lost no weight and had none of the other clinical effects of real sleeplessness over a two year period. CLASSIFICATION OF INSOMNIA
Insomnia is unquestionably one of the most common complaints in medical practice. Although there are many classifications of the condition, such as age, degree of completeness, clinical diagnosis, and whether acute or chronic, I shall refer here in particular to classification according to cause and to time of incidence. Based on the tim.e of incidence there are three types of insomnia: (1) Difficulty or delay in falling asleep, known as initial or predormitional insomnia. This is the most common type and results especially from habit, fear, worry and anxiety states, with the ability to sleep late in the morning. Laird7 goes so far as to claim that it occurs in three fourths of the population. (2) Intermittent, broken, restless sleep, which varies almost directly with age, and Laird7 believes that it occurs in about 40 per cent of adult men. This type of insomnia is commonly associated with unpleasant dreams and nightmares, and in middle-aged persons is frequently accompanied by digestive disturbances. (3) Early morning awakening, so-called terminal insomnia, with difficulty in returning to sleep. This is normal with advancing age, is common in arteriosclerosis and hypertension and, I agree with Pollock, 8 Muncie9 and many others, is especially present in mental depression. It has been found that most people wake up spontaneously during the second half of the night but fall asleep again, and that when one has had "enough" sleep, one awakens more and more frequently and finds it more and more difficult to fall asleep again until finally one remains awake. 2 When this final stage is reached by 3 or 4 or 5 o'clock in the morning instead of the usual hour of awakening (6 or 7 or 8 o'clock or so), the condition is called terminal insomnia. When this oc~urs in elderly persons, who ordinarily need less sleep than formerly but who go to bed at the usual if not an earlier hour and are worried if they do not sleep to as late an hour as previously or as late as younger people do, one need have no concern. Also, it is not merely a question of how early one awakens but how early one re-
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tires, how many hours of sleep one has had and how light or heavy a daily program one follows. Combinations of the above three types of insomnia may occur. Occasionally there is a reversal of the sleep rhythm with wakefulness by night and sleep by day, as in some cases of epidemic encephalitis and in cerebral arteriosclerosis with other manifestations of senility. CAUSES OF INSOMNIA
Insomnia is a symptom of some underlying cause or causes. There are three main groups of causes, as follows: (1) Purely external, such as extremes of heat or cold, light (especially early morning sun), noise (especially early morning traffic), uncomfortable bedding, crowding, and so forth. (2) Physical diseases and toxic causes. This covers a large number of conditions, including pain or severe discomfort from injury or disease of any kind; organic disease not especially accompanied by pain, as in tuberculosis, arteriosclerosis, thyrotoxicosis, heart disease and hypertension, organic brain disease, tinnitus aurium; or posttraumatic, or from arthritis, neuritis and the like; cerebral excitement from endogenous toxic states such as infection or uremia, as well as from exogenous toxins such as the excessive use of coffee, tea or alcohol especially in the latter part of the day; gastro-intestinal disturbances with discomfort from dyspepsia, indiscretions in diet, hunger, hypoglycemia, and so forth. (3) Psychological causes. These are the most common causes of insomnia and comprise the whole range of mental and emotional factors, the psychoneuroses (fatigue or neurasthenic, anxiety, hysterical and obsessive-compulsive states) and psychoses (especially depressed, excited, confusional and schizophrenic states), worry about and especially fear of insomnia, of the possibly serious effects of sleeplessness, of insanity and of incurability. Insomnia which is not traceable to physical disease or to some definite physiological or external origin, is most apt to be associated with anxiety about something and it is our job to find out just what that something is. It is clear that insomnia is always a definite indication that something about the patient needs investigation since it may be the end product of a multitude of possible causes and, like cough or pain or dyspnea, is only a symptom. Difficulty in sleeping dependent upon residual excitement from the day is not uncommon in sensitive, excitable, worried individuals. Some such individuals have a certain degree of recurrent insomnia of many years' duration. Psychogenic insomnia with sleeplessness as the only complaint at
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the original consultation is often complex and requires careful study, diagnosis and management. In other instances it is simple in origin and management from the very beginning. It will not be possible to discuss the characteristics and treatment of insomnia in special clinical conditions such as delirious, excited and similar states. This aspect will be found in the various clinical texts on psychiatry or psychological medicine. CLINICAL EFFECTS OF LOSS OF SLEEP
For an authoritative discussion of sleep which, unfortunately, I have no space to present, I urge you to consult the very splendid book by Kleitman 2 on Sleep and Wakefulness. He conducted experiments on partial deprivation of sleep with continued muscular activity so that the effects were due partly to lack of sleep and partly to muscular fatigue. In his standard procedure there was a waking period of sixty-two to sixty-five hours of staying awake until late in the evening of the third day of sleeplessness. He himself remained awake on various occasions to 100 hours and with the aid of benzedrine sulfate as long as 180 hours. He found, in general, no deviations from the normal range in the vegetative functions (heart rate, blood pressure, body temperature, basal metabolism, appetite, composition of the blood and urine), while the red blood cells and hemoglobin percentage showed variable results but with no general tendency to oligocythemia. In studying the effects on the nervous system, Kleitman employed two classes of tests with the following results: (1) Tests in which effort is not a determining factor (knee jerks, pupillary light response, cutaneous sensibility to faradic current, touch and pain, visual acuity, brain potentials, electrical skin resistance) showed, as with vegetative functions, no consistent variation for the group as a whole for all tests but one, namely, sensitiveness to pain, with cutaneous sensitivity to touch unchanged but to pain a progressive increase (lower threshholds). (2) Tests in which effort is a determining factor showed in general a decreased performance ability during the period of sleeplessness. Although mental and muscular performance in various tests can be maintained at normal levels if the tests are of short duration, sustained effort is impossible. The most outstanding and significant findings in all studies on lack of sleep were found to be increased sensitivity to pain, impairment of the disposition with hyperirritability and irascibility, a tendency to day-dreaming, hallucinations and other similar signs. All of these point to fatigue of higher levels of the cerebral cortex, which are in constant operation during the period of
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wakefulness and are responsible for the critical analysis of incoming impulses and the establishment of adequate responses in the light of the person's or animal's experience. Kleitman found in humans itching or slight burning sensitiveness of the eyelids, and mild mannered persons became ill tempered under continued efforts to keep them awake. Thus, the sleepy individual can make a short lasting effort but cannot sustain it. Many experiments have shown that animals die from lack of sleep:3 Menaceine's puppies after four to six days; Tarozzi's three dogs after nine, thirteen and seventeen days; although Pieron's twenty dogs were alive after from 30 to 505 hours and Okazaki's after fourteen to seventy-seven days, of Kleitman's twelve puppies kept awake from two to seven days two died without awakening after being permitted to sleep. In experimental animals which died or were killed after a period of insomnia, various brain and other nervous system changes have been reported. Kleitman concludes: 4 "From observations made on persons undergoing experimental insomnia it can be stated with assurance that no immediate untoward developments need be feared from the loss of a night's sleep, whether it be partial or complete. Prolonged, continuous wakefulness, however, even if undergone voluntarily, may cause temporary mental deterioration." Insomnia in clinical practice is a more complicated matter. Here the patient is worried about his sleeplesness; he knows that it is not voluntary or merely experimental, and it may continue not merely for days but for weeks and months. Varying with the cause, we commonly note increased fatigue, lack of concentration, deficiencies of memory, inability to perform effective mental work, impairment of muscular coordination (especially for more delicate movements), anorexia, irritability of temper, loss of weight, head and bodily paresthesias, restless and agitated pacing of the floor, and general physical and mental instabiIity.lO Weight loss, especially in depressed patients, due to insomnia, anorexia and other factors, may be as much as 20 to 50 pounds. Craig l l is right when he says: "Some persons are much more intolerant of deficient sleep than are others; indeed, some individuals will become definitely insane within a few days if sleep is not obtained." Popov5 reports such a case, with complete recovery after the patient was allowed to sleep. I also agree with Minogue12 of Australia who found that insomnia from whatever cause led to rapid mental and physical exhaustion, usually with headaches, especially a "tight band around the head" as
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if "the head were bursting." If long continued, the patients become desperate, restless, apprehensive; many are haunted by the fear of insanity; some may later become suicidal, especially if living alone, with no relatives or friends to console them, if too religious or if elderly. Minogue quite correctly concludes: "Suicide is the end result of a large number of factors, both physical and psychological. Whatever its cause, it is generally preceded by a period of insomnia with its concomitant symptoms and signs. It is imperative for us to realize the risk of suicide in such patients and also that the patient requires urgent and immediate treatment. If appropriate treatment is given, I am convinced that many a suicide can be prevented, a fact well known to all psychiatrists. But unless we, as a profession, realize that sleepless, depressed and worried patients are prone to suicide, and that such patients can be very successfully treated by modern psychiatric methods, there seems to be little hope of appreciably reducing the suicide rate in Australia." What is true of Australia is likewise true of the United States. In considering the dangers of real insomnia, one must appreciate the possibility of a vicious circle with insomnia aggravating the nervous and mental condition, and vice versa. I have summarized 13 the situation briefly in a previous discussion in the following words: "It is not merely the direct results of lack of sleep but its indirect and psychological results which are of serious import. The patient's hours of wakefulness at night, with everyone else sleeping and all quiet~ may seem to him very much longer than they in fact are. It is also during such periods at night that his rushing thoughts, emotionalism, anxiety, worries and fears take possession of him in more unrestrained fashion. Then come his worries over the real or imagined dangers of insomnia. Being more unstable because of insomnia, he is inclined the following day to be more in the grip of his anxieties and fears. His worry about the lack of sleep leads to an excessive interest in whether or not he will sleep well. He may have actual despair from his sleeplessness. Fear of the night, of insomnia and of bed time may become perdominant. Fear of insanity may result from insomnia primarily or be exaggerated by it. Although insomnia is only one cause of the fear of insomnia in psychoneurotics (and psychotics) it is ~n important cause. Continued sleeplessness may lead to a feeling of lack of self-confidence and self-control." In all cases of persistent, prolonged insomnia the patient should be studied carefully to determine whether or not a real mental depression is not the actual clinical condition present, and, if so, it should be treated as sm:h, with, if ~evere enoug-h ami indicated, hospitaliza-
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tion and so-called electroshock therapy; in selected cases estrogen therapy15. 16 in the female and androgen therapy17 in the male have apparently been of value in true involutional melancholia. GENERAL MANAGEMENT OF INSOMNIA
In all cases a careful sequential history of the onset and development to date is essential. This should include its degree, duration, effects, probable cause of onset, factors responsible for its continuation, and the patient's attitude toward his condition. His other complaints should be gone into sufficiently fully. Review the patient's daily program-his time of arising, routine of the day, hour of retiring, the amount and character of his sleep before and since the onset of his . . msomrua. A personality estimate and determination of the mental condition. with decision as to the existence or absence of a psychoneurosis or psychosis and the approximate clinical diagnosis can usually be made during the first extended consultation. Take the complaint of insomnia as seriously as you do (or should) any other symptom. At the outset a full physical examination should be made with definite exclusion of obvious causes (such as pain, dyspnea, pruritus), diseases of the gastrointestinal, circulatory, respiratory or excretory systems, hypertension, organic neurologic diseases and alcoholic toxic states. Whatever laboratory tests are really necessary should not be omitted. By this time you should have a more definite opinion concerning the patient and his complaint. Each case is an individual affair. No fixed rules can be laid down. Unless the patient is willing to put himself under your care, to see you frequently enough and to permit proper study and supervision, it is better to give merely general advice, outline the situation and not prescribe hypnotics except for two or three nights and then not to be refilled. Explain your reasons to the patient. All psychoneurotic patients with insomnia, except of the sligHtest degree, are much better sleeping alone. All clocks are generally best removed. A dark, quiet, properly ventilated room is desirable. Each individual has his favorite, preferred choice of bedspring, mattress, bedding, pillow arrangement, ventilation and posture in bed. If . there is increased blood pressure, have the patient try using no pillow. If there is sensitiveness to cold, a warm bed-even with hot water bottles-is in order. If cold feet while in bed are a source of discomfort, help may be found in a hot foot bath at bedtime, or hot water
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bag to the feet, being sure to avoid burns, or the patient may wear woolen socks to bed. If the patient is hungry at bedtime, milk or warm soup with crackers a half hour before retiring should be soporific. If awakening occurs from hunger, a glass of milk and crackers may be taken at the time of awakening. If there is overuse of coffee, tea or alcohol, reduce the amount consumed during the latter part of the day or after lunch, especially at or near bedtime. The effect of coffee and tea varies from one person to another. If there is flatulent distention of the stomach or intestines, try onehalf glass of water with 10 to 15 grains (0.65 to 1 gm.) of sodium bicarbonate at bedtime. For disturbing symptoms in medical or surgical conditions, such as cough or dyspnea, relief as necessary is in order. Some patients are helped, others made worse, by a glass of hot whiskey or water, by reading, or by attempts at muscle relaxation at bedtime. Gentle massage, especially of the spinal muscles, just before the usual sleeping time is apt to be valuable, especially in neurasthenics and bed patients. To exclude the early morning light, opaque window shades (dark green shades instead of or in addition to yellow, tan or white ones) should be drawn low at bedtime. For sleeping by day, the use of an opaque screen about two feet from the window is helpful. A void having the light fall directly on the head. Sedative hydrotherapy may be employed in several ways: as prolonged (one quarter to one-half hour) warm (96 0 F.) bath; cold wet pack for three-quarters to one hour; or, in excited states, neutral tub baths for two or three hours or continuously, especially with an ice cap to the head. The last is always, and the second is usually, a hospital procedure. Suggestion, assurance, diversion, distraction, release of anxiety and tension are occasionally of service as conditioning processes to induce sleep: drinking or eating or even a warm bath; muscular relaxation; various psychological procedures such as listening to one's breathing, prayer, autosuggestion of Coue, naming categories following the alphabet, and so on. If sleeplessness follows a period of unusually concentrated or prolong~d mental work, a short vacation with plenty of rest and sleep should be advised, often at the onset, with the addition of mild hypnotic medication. T know that many of the above suggestions cannot be carried out in certain patients owing to limitations of living quarters, hours of
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employment and financial situation, but no symptom demands such varied therapeutics. As Kleitman6 concludes: "Insomnia, in the sense of hyposomnia, is nearly always traceable to some disturbing factor, capable of keeping the cortical centers, or the wakefulness center in the hypothalamus, directly in a state of prolonged activity. The therapeutics of insomnia consist in the removal of the disturbing factors and, if that fails, in the use of depressing drugs." In the majority of cases no physical cause can be found for the insomnia and the patient needs a combination of a common sense exploration of his mental and emotional problems with psychological management, a survey of his daily program of activity, and the rational use of hypnotic drugs. PSYCHOLOGICAL ASPECTS AND PSYCHOTHERAPY
In considering psychogenic insomnia, emotional conflict is so important that its consideration is really an introduction to the problem of psychoneuroses and so-called functional psychoses. Thus, the management of the patient goes step by step with the treatment of the symptom of sleeplessness. This means an investigation of the patient's personal problems, his state of health, his daily program, domestic (marital and family), financial, occupational, social, recreational, sexual, religious, and ethical-moral adjustments. The attitude of the physician must very definitely be one which inspires confidence. The physician must have and show confidence in his own ability to help the patient recover and in the patient's ability to regain his equilibrium. In the treatment of a disease associated with insomnia, one must remember that in continued pain with prolonged insomnia, especially in unstable individuals, eventual psychoneurosis or even psychosis may result. In like manner organic disease of any sort may clear up and insomnia continue. Discuss the past anxieties which led to or the present anxieties which maintain the insomnia. With time, interest, sympathy, patience and understanding in the very first interview or the first few interviews, the patient will confess his anxieties, medical and nonmedical. SOme can, others cannot, be settled by discussion. If you cannot remove the anxiety responsible for the sleeplessness, at least reassure the patient as much as possible. Use explanation, suggestion and readjustment of his daily program, attitudes and ambitions, as the case may be. If intensive personality study is indicated, I do not favor adhering to anyone school of psychological thought, Freudian or otherwise,
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but study each patient individually, letting the quips fall where they may. I do not find any real basis to the current systems of dream interpretation and their supposed invariable importance and value in unearthing the causes of the disorder. Hypnosis is ordinarily of no, little or temporary value and it may not be possible to use it in sleeplessness in office patients. PHARMACOTHERAPY: THE USE OF HYPNOTIC DRUGS
Owing to space limitation I shall confine my discussion to the pros and cons of using hypnotics in general and to technic and precautions in their use. The chemistry, characteristics, dosage and methods of administration of the various drugs can be found elsewhere, as in the presentations by Weiss,18 Feiling,19 Fantus,20 Winans,21 Dercum,22 Diethelm,23 ROSS,24 Crichton-Miller 25 and Grabfield. 26 For special attention to the barbituric acid group I refer you to Weiss18 and the special report of the Journal of the American Medical Association. 27 Goodman and Gilman 28 give a comprehensive discussion. The Case For and Against the Use of Hypnotics.-Sleeplessness due to pain and other discomfort requires necessary symptomatic relief, even morphine or codeine. Hyoscine is used exclusively in selected cases in psychiatric hospital practice. Bromides are rarely effective in insomnia of real consequence. Chloral and paraldehyde, not used as frequently now as formerly, are in my opinion for hospital and sanitarium rather than home use in ambulatory office patients. By hypnotics I refer more particularly to the drugs of the barbituric acid group such as barbital, veronal, medinal, sodium amytal, ipral, nembutal, seconal, "delvinal" sodium and many others, and much less to the so-called sedative group, bromides, chloral, paraldehyde), but not at all to the so-called euphorotics (alcohol, opium, morphine, heroin, cocaine). I agree with others that with a change of dosage a so-called sedative may produce hypnosis or narcosis. Surely there can be no scientific objection to the desirability or necessity of medication for actually disturbing symptoms of emotional origin, as for instance the temporary use of hypnotics for psychogenic insomnia while the patient is being studied and treated causatively. And yet there is a surprising disagreement in attitude and policy on this important clinical problem. This is especially so in the case of insomnia accompanying the psychoneuroses. As p3 have said elsewhere, among the large number of psychotherapists and psychopathologists who are in direct opposition or do not openly advocate or even mention the occasional necessary use of hypnotics in the treat-
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ment of insomnia in the psychoneuroses, I found such names as Dubois, lanet, Freud, lung, Adler, McDougall, Prince, Dejerine and Gauckler. Yet we find that Dejerine and Gauckler29 admit that the patient with insomnia of phobic origin often clings to his fear of insomnia so strongly that the bad habits which he has formed are frequently kept up in spite of all psychotherapeutic efforts. As a consequence of the many arguments against the use of hypnotics by men of the highest standing in psychopathology, and of newspaper items emphasizing the dangers of habit formation or referring to their employment for suicidal purposes, many physicians fear or apologize for prescribing hypnotics under any circumstances. This in my opinion is illogical, unscientific and unfair to patients, the medical profession and the public in general. The main arguments against their use, and answers to these arguments, have been given by me14 elsewhere and are herewith summarized: 1. The use of hypnotics is not causal treatment, but palliative; however, symptomatic treatment is employed elsewhere in medicine. 2. There is danger of toxic effects; but their avoidance, as with other drugs, is merely a question of technic and precautions. 3. Self-medication may ensue; but with proper precautions this should not result. 4. Their use is a temporary and not permanent help or solution; hut this applies to all palliative therapy. 5. It is a resort to an artificial crutch; but so are many other procedures in practice. 6. It is a line of least resistance; but it need not be so abused. 7. Other necessary treatment may be neglected by physician and/or patient; but it should not be. 8. It gives the patient the wrong idea of the causes and of the fundamental importance of the psychotherapeutic aid required; hut it does not if properly handled. 9. There is danger of drug addiction. 10. The drug ordered may be used for suicidal purposes. The last two arguments will be answered immediately: I fully endorse the views of Craig9 who spoke from much experience when he said: "As a profession we are unduly timid of giving hypnotics and in consequence the public, as a whole, objects to them. Brought up as I was in the same attitude, long experience has taught me the folly of such an outlook. The chief objection, I gather, is the fear of inducing a habit. Once more experience has taught me to be much more afraid of the effects of sleeplessness than of any danger of producing an addiction, a danger which is almost negligible. Let those persons who
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are constantly talking about addiction produce the evidence upon which they base their statements." Although the suicidal use of the drug ordered is apt to occur in the psychoses and alcoholism, precautions in the method of prescribing should prevent this. Suicidally inclined patients, not psychoneurotic, have many sources (newspaper items and drug stores) of information concerning hypnotics. Suicidal use is especially apt to take place in worried depressions. But an important aggravant of this possibility is the unrelieved, prolonged, marked insomnia present in such psychotic states. Psychoneurotic patients are notoriously not inclined to suicide. Too many physicians make the mistake of misdiagnosing real mental depressions, even of the worried or agitated type, as psychoneuroses, and in such depressions the need of sufficient sleep is absolutely essential and fundamentally basic in treatment. In fact, practically all truly depressed patients with insomnia are in need of the aid of hypnotic medication since they are especially resistant to all methods of psychotherapy. Such depressed patients should, if their condition is pronounced enough, be hospitalized, hypnotics used as required, necessary precautions against suicide observed, and so-called electroshock therapy instituted when indicated. Furthermore, prolonged, severe insomnia may lead to depression and suicidal thoughts and attempts. One of the common characteristics of depression, if not slight or mild, as in excited and other states, is the inability to secure a sufficient amount of sleep with moderate doses of hypnotics. Craig9 was certainly fully justified when he insisted that "As with every other disorder, the sooner we treat sleeplessness the morc quickly we shall be able to correct it, and, what is most important of all, sleeplessness quickly relieved leaves no terrors behind it compared with prolonged insomnia. The physicians who are most likely to produce a drug habit are those who have permitted their patients to become terrified by the experience through which they have passed. "In the case of hypnotics for insomnia, it is generally true that it is not the drug but the lack of confidence in the ability to sleep without it which may become a habit, with the result that they are reluctant to break away from the means which have afforded them relief." It is our duty to see to it that patients are satisfied and relieved if at all possible by nondangerous methods adapted to the particular case. Our personal preferences should not be made rigid practices. We surely are not justified in dismissing patients suffering from insomnia by merely telling them that it does not matter whether they
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sleep or not, or that they will sleep if they will not worry about it, or to forget it. Even if he is exaggerating his degree of insomnia, the patient must be satisfied that he is sleeping soundly and sufficiently; the general condition of the patient should always be the real guide. If the patient is in a condition in which he cannot be satisfied by explanation or by other measures, hypnotics should be temporarily used. If you can easily and quickly produce sleep, you have a much better chance of getting a psychological hold on the patient and of increasing his confidence in himself. A period of sleep promptly given helps rapidly to break up the habit of sleeplessness, to diminish or to eliminate the other bad physical and psychological effects of insufficient sleep, and to put the patient in a psychological condition more suspectible to psychotherapy and physiotherapy. At the same time, fear of the medication given him which is so often present and deep rooted should be removed. As a matter of truth, if hypnotics are not used for insomnia, one can never be sure that other measures will produce sleep. Therefore, without the employment of hypnotics, one cannot give any definite promise of sleep on any particular night. But with medication one is fortified and can assure the patient that with a sufficient dosage and with one or the other of the hypnotics or some combination of them, sleep can positively be obtained. Furthermore, if you continue to assure a patient that he will sleep without hypnotics but his sleeplessness continues, you are gradually losing the confidence of your patient. In fact, as ROSS30 says, it is certain one can be just as unscientific in withholding hypnotics as in giving them when it is not indicated. Technic and Precautions in Using Hypnotics.-I shall here enumerate many practical "do's and don'ts." Deal with your patient insofar as possible on the principle of "open covenants openly arrived at." Explain to the patient that you are using hypnotics temporarily, that you will study and treat his general condition and that hypnotics will be gradually omitted. As many patients fear the use of hypnotics, after explaining your plan to the patient, get his views and attitude. Assure him that if he takes only what medication you order and remains under your medical supervision and sees you as frequently as you wish, he need fear neither the "dope habit" nor toxic effects. If occasionally the patient at first prefers not to take hypnotics temporarily even when so requested by you, he will generally agree to do so after he gains more confidence in you.
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All prescriptions for hypnotics or sedatives should have a "non repetatur" or "Do not refill" order. Do not prescribe hypnotic tablets or capsules by the bottle. Order only enough to last until the next visit. Do not tell the patient to take hypnotics as he needs or wishes. And do not have him renew his prescription on his own initiative or renew the prescription for hypnotics routinely by telephone. Such methods lead to self-medication with its possible dangers. If the patient is suicidal, and this can usually be determined at the first visit, do not give the prescription or medication directly to him but to someone else (relative, nurse) who will have control of it. Such suicidal patients, of course, really need hospitalization. Do not promise positive sleep the first night but promise that sufficient sleep can be obtained shortly with proper dosage and combination of hypnotics. Give a large enough dose at once to insure sleep, if possible, the very first night of treatment. Explain in advance some of the possible undesirable results (such as drunken feeling) the morning after taking the drug and until the dose is adjusted. After a sufficient number of good nights of sleep the usual patient readily agrees to gradual reduction of dosage until it can be omitted altogether. Sometimes at this stage, if he prefers, one dose of the drug can be ,laced within reach of the patient to be used, if he wishes or really needs it, without rising. This may give him the degree of assurance which will lead to peaceful sleep. In 6~ce practice it is best not to continue using hypnotics for more than two to three weeks or so without attempting to reduce the dose gradually. The hypnotic should preferably be varied as the patient improves or fails. to get results. If petmanent relief depends upon a knowledge of the cause of the insomnia and the patient refuses to cooperate in finding out the cause, one may refuse to give hypnotics until he changes his attitude. A supply for only two or three days at a time should be ordered as a rule. In selected cases during the convalescent phase this may be somewhat extended. It 'is well to have at least a telephone report daily for the first few days, See the patient, if at all possible, at least two or three times a week in the first week; the frequency thereafter varies with each case. If the patient callnot be seeq frequently enoug-h to check up on th~
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progress, the diagnosis, possible toxic effects, the advisability of increasing or decreasing the dose or best time of administration or of changing the medication, refuse further to treat the patient or to assume any responsibility. In the case of the average office patient I give the prescription directly to the patient or relative without fear of misuse since I have examined the patient sufficiently, have arrived at a tentative diagnosis, have made reasonably sure that he is not suicidal, have given an explanation and the plan of procedure and have had an understanding with the patient. This does not apply to depressed patients, especially if more than slightly depressed, and particularly if suspected of being suicidal, in which case, unless hospitalization seems definitely indicated, the hypnotic is under the control of someone else in the home. If preferred, you may dispense the hypnotic yourself or have special arrangements with the druggist to give the hypnotic without the patient knowing its name. It is much better to know a few selected hypnotics well than to know too many too little. Use hypnotics judiciously combined with causal therapy, including psychotherapy plus any palliative physiotherapy advisable. When, from the history and condition of the patient, real help is needed for obtaining essential sleep, hypnotics should be used not merely as a last resort and half-heartedly but promptly from the very first visit and wholeheartedly-with the practical suggestions as to technic and precautions enumerated above. SO·CALLED ELECTROSHOCK AND INSULIN SHOCK THERAPY IN PSYCHOSES WITH INSOMNIA
Where insomnia is part of a psychosis, we find that, as the psychosis is improving, sleep without medication is one of the earliest signs of such improvement. This applies to the use of so-called insulin shock and electroshock treatment, which has almost universally displaced metrazol. In depressions, including agitated depressions, in which pronounced and prolonged insomnia is common, so-called electroshock treatment produces remarkable results in a large proportion of patients, with a clearing up of the sleeplessness in many cases in a truly unbelievable manner. The patient soon gets along without drugs. It cannot be too often emphasized that many cases of depression are wrongly diagnosed psychoneurosis and so improperly treated. Although mild depressions may be treated on an ambulatory, homeoffice, extramural basis, others, especially the more pronounced and
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more particularly the agitated types with marked insomnia and SUIcidal thoughts or tendencies, need immediate hospitalization. Schizophrenic patients, especially early, may be greatly helped or may recover by so-called electroshock and/or insulin shock therapy plus psychological management. BIBLIOGRAPHY 1. Kingman, R.: The Insomniac. New York M. J. & Rec., 129:683.c687; 130:17-
21, 1929. 2. Kleitman, Nathaniel: Sleep and Wakefulness, as Alternating Phases in the Cycle of Existence. Chicago, University of Chicago Press, 1939. 3. Ibid., Chapter 21, Experimental Deprivation of Sleep. 4. Ibid., Chapter 27, Insomnia or Hyposomnia, p. 381. S. Ibid., p. 381. 0. Ibid., p. 527. 7. Laird, Donald A.: Cyclopedia of Medicine and Surgery. Philadelphia, F. A. Davis Co., 1934, Chap. 11, pp. 307-313. 8. Pollock, L. J.: Disorders of Sleep. M. CLIN. NORTII AMERICA, 13:1111, 1930. 9. Muncie, Wendell: Insomnia in Clinic Psychiatric Practice. Johns Hopkins Hosp. Bull., 55:131-153 (Aug.) 1934. 10. Worster-Drough, c.: Insomnia in Early Mental Disease. The Lancet Extra Numbers No. 2, London, Wakley & Son, Chap. 7, pp. 37-41. I I. Craig, Maurice: The Early Treatment of Mental Disorder in Early Mental Disease. The Lancet Extra Numbers No. 2, London, Wakley & Son, Chap. 41, pp. 191-194. 12. Minogue, M. J.: Symptoms (Insomnia) Preceding Suicide. M. J. Australia, 2: 598.c600 (Oct. 31) 1936. 13. Solomon, Meyer: Shall Hypnotics Be Used in the Treatment of Insomnia in the Psychoneurosis. M. J. & Rec., 138:22-26 (July 5) 1933. 14. Ibid., pp. 22-25. 15. Danziger, Lewis: Specific Treatment of Psychosis Due to Estrogen Deficiency. Arch. Neur. & Psychiat., 51.:462-468 (May) 1944. 16. Darken, Marjorie A. and Burlingame, C. Charles: Evaluation of Laboratory Controlled Estrogenic Therapy in the Psychoses. Dis. Nerv. System, Vol. 5, No. 7, July, 1944. 17. Danziger, Lewis, Schroeder, Harold T. and Unger, Arthur A.: Androgen Therapy for Involutional Melancholia. Arch. Neur. & Psychiat., 51:437461 (May) 1944. 18. Weiss, Soma: Indications and Dangers of Sedatives and Hypnotics, with Special Reference to the Barbituric Acid Derivatives. Internat. Clinics, pp. 38-66 (March) 1936. 19. Feiling, A.: Insomnia (Use of Hypnotics). Practitioner, 129:130--139 (July) 1932. 20. Fantus, B.: Therapy of Insomnia at Cook County Hospital. J.A.M.A., 102: . 1846-1848 (June 2) 1934. 21. Winans, H. M.: Insomnia. Internat. Clin., 1:39-55 (March) 1935. 22. Dercum, Francis X.: Rest, Suggestion and other Therapeutic Measures in Nervous and Mental Diseases, 2nd ed. Philadelphia, P. Blakiston's Son & Co., 1917. 23. Diethelm, Oskar: Treatment in Psychiatry. New York, The Macmillan Co., 1936. 24. Ross, T. A.: Insomnia. Practitioner, 144:329-336 (April) 1940.
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25. Crichton-Miller, H.: Insomnia: An Outline for the Practitioner. E. Arnold & Co., London, 1930. 26. Grabfield,G. P.: Treatment of Insomnia. M. CLIN. NORTH AMERICA, 19: 1597-1601 (March) 1936. 27. Barbituric Acid and Derivatives. Several contributors. Pamphlet published by American Medical Association. 28. Goodman, Louis and Gilman, Alfred: Pharmacologic Basis of Therapeutics, Chaps. 9, 10, 11 and 12. New York, The Macmillan Co., 1941. 29. Dejerine, J. and Gauckler, E.: The Psychoneuroses and Their Treatment by Psychotherapy. Authorized translation by Smith Ely Jelliffe. Philadelphia, J. B. Lippincott Co., 1913, p. 364. 30. Ross, T. A.: The Common Neuroses. London, Edward Arnold & Co., 1923, p.95.