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Journal of Psychoactive Drugs Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujpd20

Treating Insomnia: Pharmacological and Nonpharmacological Approaches Donald L. Bliwise

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Stanford University Medical Center , 211 Quarry Road, Hoover Pavilion N2A, Stanford , California , 94305 Published online: 20 Jan 2012.

To cite this article: Donald L. Bliwise (1991) Treating Insomnia: Pharmacological and Nonpharmacological Approaches, Journal of Psychoactive Drugs, 23:4, 335-341, DOI: 10.1080/02791072.1991.10471604 To link to this article: http://dx.doi.org/10.1080/02791072.1991.10471604

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Treating Insomnia: Pharmacological and

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Nonpharmacological Approaches" Donald L. Bliwise, Ph.D. * Abstract - Insomn ia is a commonly encountered condition in clinical practice. The prev alence of self-reported poor sleep increases with age and is more common in women. Th ere are clear associations between poor sleep and psychi atric disturbance; howev er, causality in this regard may be complex, and there are at least some insomniacs who show high somati c tension without marked psychopathology. The development of chr onic insomnia can be conceptu alized as involvin g predi sposing, precipitating, and perpe tuating fac tors. Pharma cological treatments for insomnia most typically involve judicious and intermittent usage of a benzo diazepine hypnotic. A var iety of such med icat ion s are av ailable , with varying abso rp tion and elimination characteristics . Ben zod iazep ines are preferr ed over antid epressants in the treatment of insomni a in individuals without major psychiatric disord er because of few er side effects and a larger margin of safety. Nonpharm acol ogi cal treatments typically rely on elements of sleep hyg iene, stimulus control, sleep restriction, and chronotherapy. The establishment of good patient -clinician rapport and the workin g through of unfounded beliefs and unreali stic expectations of the sleep experience are also important components of the behavioral treatm ent of insomn ia. Use of such techn iques, particularly when comb ined in a treatment pa ckage, has shown appreciable benefits in improving sleep . Keywords - bcn zodi azcpines, insomn ia, nonpharmacological treatm ents , ph armacologi cal treatments, sedative-hypnotics, valerian

DESCRIPTION OF INSOMNIA

Insomnia is one of the most common yet difficult condition s encountered in clinical practice . This brief review will focus on only a few of the specific issues in the assessment and treatment of patients with insomnia. It docs not, for example, cover in great detail such important and significant topics as the organic etiologies of insomnia and related nosological issues, the insomnia subtypes related to dysfunction of circadian rhythms, and the use of psychotherapy rather than behavioral therapy to treat insomnia. However, excellent recent overviews of insomnia, longer and more expansive in scope, are available and the reader is directed to them to complement the present brief and limited article (Hauri 1991; Gillin & Byerly 1990; Morin & Kwentus 1988; Spielman, Caru so & Glovinsky 1987).

Estimates of insomnia prevalence vary widely, depending on the specific question asked, the severity and duration of the sleep disturbance, the time frame (e.g., last week versus last year), population characteristics (e.g., urban/rural , Black/White), and perhaps most notably, the sex and age of the individuals involved. At every age , women report more disturbed sleep than men. As for age itself, nearly all surveys concur in showing that the prevalen ce of poor sleep increa ses dramatically from young adulthood into old age. For example, the proportion of individuals reporting trouble with sleep (often or all the time) increases from about9 % at age 20- 29 to about 21 % at age 60 -69 (Karacan et al . 1976). Other surveys have shown prevalen ce figures approximating 50% by age 65 . Most typically the complaint of difficulty in maintaining sleep increases with age . Generally speaking, problems with falling asleep are more

t Supported by National Inst itute on Aging Grant No. AG..()6()()6. · Sleep Disorders Clinic , Stanford University Medical Center, 211 Quarry Road , Hoover Pav ilion N2A , Stanford, Cal iforn ia 94305 .

Journal ofPsychoa ctive Drugs

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Figure 1. Successive stages of factors leading to chronic insom nia (adapted from Spielman, Caruso & Glovinsky 1987).

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Treating insomnia: pharmacological and nonpharmacological approaches.

Insomnia is a commonly encountered condition in clinical practice. The prevalence of self-reported poor sleep increases with age and is more common in...
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