- Email: [email protected]
Lifeline
In Context
Focal point Losing sleep In 1939, in a letter to The Lancet, the link between anxiety and sleeplessness was suggested on the basis of experiences from the Spanish Civil War and the early days of the Second World War.1 Insomnia was depicted as the result of life-threatening living conditions, and supposedly cured by calming the patient with relaxation techniques or sedative substances. These assumptions prevailed until recently, and may have contributed to a view of insomnia not as a brain disorder, but merely as a reflection of stressful life conditions or a symptom of other disorders. Review articles on insomnia usually emphasise epidemiology, diagnosis, pharmacological and psychological treatment and, more recently, the neurobiological aspects.2 Current psychological theories emphasise the role of stressful life experiences, maladaptive behaviours, cognitive factors, and learned negative associations from a top-down perspective.3–5 This perspective has served as the basis for cognitive-behavioural therapy as the first-line treatment for insomnia (CBT-I).6 In addition, psychophysiological research has suggested the concept of central nervous system hyperarousal as a core pathophysiological pathway.7 This echoes the first neurobiological description of insomnia by von Economo,8 based on his neuropathological work in encephalitis lethargica. He reported that a minority of affected individuals did not show symptoms of fatigue or hypersomnia, but developed choreatic movements accompanied by severe insomnia. He suggested that specific CNS lesions, especially in the midbrain, are relevant for sleep, thus proposing the concept of a localisable sleep center in the brain.
Kai Spiegelhalder, Dieter Riemann 1 2
3 4 5
6
7
8
Anonymous. Insomnia. Lancet 1939; 234: 1123. Riemann D, Nissen C, Palagini L, Otte A, Perlis ML, Spiegelhalder K. The neurobiology, investigation, and treatment of chronic insomnia. Lancet Neurol 2015; 14: 547–58. Spielman AJ, Caruso LS, Glovinsky PB. Behavioral perspective on insomnia. Psychiatr Clin North Am 1987; 10: 541–53. Harvey AG. A cognitive model of insomnia. Behav Res Ther 2002; 40: 869–93. Espie CA, Broomfield NM, MacMahon KM, Macphee LM, Taylor LM. The attention-inattention-effort pathway in the development of psychophysiologic insomnia: an invited theoretical review. Sleep Med Rev 2006; 10: 215–45. Riemann D, Perlis ML. The treatments of chronic insomnia: a review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Med Rev 2009; 13: 205–14. Riemann D, Spiegelhalder K, Feige B, et al. The hyperarousal model of insomnia: A review of the concept and its evidence. Sleep Med Rev 2010; 14: 19–31. Von Economo C. Der Schlaf als Lokalisationsproblem. In: Pötzl O, ed. Der schlaf. Mitteilungen und stellungnahme zum derzeitigen stand des schlafproblems. München: JF Lehmans Verlag, 1929: 38–53.
www.thelancet.com/neurology Vol 14 June 2015
Lifeline Alfonso Fasano graduated from the Catholic University of Rome, Italy, in 2002 and became a neurologist in 2007. After a 2-year fellowship at the University of Kiel, Germany, he completed a PhD in neuroscience at the Catholic University of Rome. In 2013 he joined the Movement Disorder Centre at Toronto Western Hospital, where he is the co-director of the surgical program for movement disorders. He is also an associate professor of medicine in the Division of Neurology at the University of Toronto. What has been the greatest achievement of your career? I could say having been invited to join Anthony Lang and his team at the Movement Disorder Centre in Toronto. However, I’m also thinking of all those little miracles that we witness every day as doctors: a child regaining his walking or an elderly patient getting back to work and making new plans for the future.
See Review page 625
What do you think is the most neglected field of science or medicine at the moment? Neurology comprises thousands of rare “orphan” diseases, which are neglected because research is too often driven by the economic interests of pharmaceutical companies. What inspires you? Patients’ needs. Indeed, patients should be the only starting and ending points of medical research. If you had not entered your current profession, what would you have liked to do I like any form of human expression, especially art. When I was 22 I was about to quit medicine to become a musician. I still enjoy music and—in general—creativity and passion, something that every researcher should use. What would be your advice to a newly qualified doctor? To always follow your passion because it is what drives the greatest effort from humans. Compromises are challenging but fundamental. In Aristotle’s words, motivation—not intelligence—makes the difference. What are you currently reading? Essays in Love, by Alain de Botton. What is your idea of a perfect day? The calibrated mix of naps, art, Zen, love, instinct. If you were Bill Gates, how would you spend your fortune? Building schools and paying teachers everywhere in the world. Knowledge is the real essence of human progress. It teaches us that gender, age, religion, and provenance do not really count. If you could have dinner tonight with a famous person of your choice (dead or alive), who would it be? Notoriety aside, I would pick my best friends and my family. My work keeps me away a lot and they deserve more.
571
Focal point Losing sleep In 1939, in a letter to The Lancet, the link between anxiety and sleeplessness was suggested on the basis of experiences from the Spanish Civil War and the early days of the Second World War.1 Insomnia was depicted as the result of life-threatening living conditions, and supposedly cured by calming the patient with relaxation techniques or sedative substances. These assumptions prevailed until recently, and may have contributed to a view of insomnia not as a brain disorder, but merely as a reflection of stressful life conditions or a symptom of other disorders. Review articles on insomnia usually emphasise epidemiology, diagnosis, pharmacological and psychological treatment and, more recently, the neurobiological aspects.2 Current psychological theories emphasise the role of stressful life experiences, maladaptive behaviours, cognitive factors, and learned negative associations from a top-down perspective.3–5 This perspective has served as the basis for cognitive-behavioural therapy as the first-line treatment for insomnia (CBT-I).6 In addition, psychophysiological research has suggested the concept of central nervous system hyperarousal as a core pathophysiological pathway.7 This echoes the first neurobiological description of insomnia by von Economo,8 based on his neuropathological work in encephalitis lethargica. He reported that a minority of affected individuals did not show symptoms of fatigue or hypersomnia, but developed choreatic movements accompanied by severe insomnia. He suggested that specific CNS lesions, especially in the midbrain, are relevant for sleep, thus proposing the concept of a localisable sleep center in the brain.
Kai Spiegelhalder, Dieter Riemann 1 2
3 4 5
6
7
8
Anonymous. Insomnia. Lancet 1939; 234: 1123. Riemann D, Nissen C, Palagini L, Otte A, Perlis ML, Spiegelhalder K. The neurobiology, investigation, and treatment of chronic insomnia. Lancet Neurol 2015; 14: 547–58. Spielman AJ, Caruso LS, Glovinsky PB. Behavioral perspective on insomnia. Psychiatr Clin North Am 1987; 10: 541–53. Harvey AG. A cognitive model of insomnia. Behav Res Ther 2002; 40: 869–93. Espie CA, Broomfield NM, MacMahon KM, Macphee LM, Taylor LM. The attention-inattention-effort pathway in the development of psychophysiologic insomnia: an invited theoretical review. Sleep Med Rev 2006; 10: 215–45. Riemann D, Perlis ML. The treatments of chronic insomnia: a review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Med Rev 2009; 13: 205–14. Riemann D, Spiegelhalder K, Feige B, et al. The hyperarousal model of insomnia: A review of the concept and its evidence. Sleep Med Rev 2010; 14: 19–31. Von Economo C. Der Schlaf als Lokalisationsproblem. In: Pötzl O, ed. Der schlaf. Mitteilungen und stellungnahme zum derzeitigen stand des schlafproblems. München: JF Lehmans Verlag, 1929: 38–53.
www.thelancet.com/neurology Vol 14 June 2015
Lifeline Alfonso Fasano graduated from the Catholic University of Rome, Italy, in 2002 and became a neurologist in 2007. After a 2-year fellowship at the University of Kiel, Germany, he completed a PhD in neuroscience at the Catholic University of Rome. In 2013 he joined the Movement Disorder Centre at Toronto Western Hospital, where he is the co-director of the surgical program for movement disorders. He is also an associate professor of medicine in the Division of Neurology at the University of Toronto. What has been the greatest achievement of your career? I could say having been invited to join Anthony Lang and his team at the Movement Disorder Centre in Toronto. However, I’m also thinking of all those little miracles that we witness every day as doctors: a child regaining his walking or an elderly patient getting back to work and making new plans for the future.
See Review page 625
What do you think is the most neglected field of science or medicine at the moment? Neurology comprises thousands of rare “orphan” diseases, which are neglected because research is too often driven by the economic interests of pharmaceutical companies. What inspires you? Patients’ needs. Indeed, patients should be the only starting and ending points of medical research. If you had not entered your current profession, what would you have liked to do I like any form of human expression, especially art. When I was 22 I was about to quit medicine to become a musician. I still enjoy music and—in general—creativity and passion, something that every researcher should use. What would be your advice to a newly qualified doctor? To always follow your passion because it is what drives the greatest effort from humans. Compromises are challenging but fundamental. In Aristotle’s words, motivation—not intelligence—makes the difference. What are you currently reading? Essays in Love, by Alain de Botton. What is your idea of a perfect day? The calibrated mix of naps, art, Zen, love, instinct. If you were Bill Gates, how would you spend your fortune? Building schools and paying teachers everywhere in the world. Knowledge is the real essence of human progress. It teaches us that gender, age, religion, and provenance do not really count. If you could have dinner tonight with a famous person of your choice (dead or alive), who would it be? Notoriety aside, I would pick my best friends and my family. My work keeps me away a lot and they deserve more.
571