Insomnia Insomnia

Foreword
It is a pleasure and honor for me to introduce this most important Clinical Handbook
of Insomnia, edited by Hrayr Attarian, MD. For too long, the complaint of
insomnia has been ignored, trivialized, or summarily (often erroneously) attributed
to underlying or pre-existing psychiatric or psychological problems (themselves
often ignored or trivialized). This book clearly underscores the fact that insomnia
extracts a huge toll—in the form of personal misery, societal financial burden, lost
productivity, and strained interpersonal relationships.
One reason the complaint of insomnia is often not pursued by physicians is that
the evaluation and management may be time consuming and therefore difficult to
execute in the current medical climate. Another is that physicians tend not to want
to deal with conditions that are perceived as difficult or discouraging to manage.
Many physicians have not had positive reinforcement from predictable success in
treating insomnia—their past experience does not anticipate a favorable outcome.
Clinical Handbook of Insomnia provides a systematic approach to the diagnosis
and management of insomnia, which will result in more gratifying doctor–patient
encounters—with the patient improving, and the physician being positively reinforced.
As with other constitutional symptoms, such as pain, fever, or weight loss, insomnia
is a manifestation of myriad underlying conditions that, appropriately identified,
is effectively treatable. The algorithm in Chapter 4 is particularly helpful in
this regard.
One important emphasis of Clinical Handbook of Insomnia is the growing scientific
evidence that much insomnia has biological underpinnings, with many individuals
having a genetic or constitutional predisposition to develop insomnia—
triggered by environmental events or situations. Once this insomnia has developed,
it may become persistent, despite resolution of the initial instigators, and will not
spontaneously improve until behavioral and/or pharmacologic treatment is undertaken.
This is reason enough for aggressive treatment of acute, situational insomnia—to
prevent the development of persistent psychophysiologic, learned, or
conditioned insomnia.
Furthermore, it is now clear that insomnia, initially not associated with depression,
is a major risk factor for the development of depression—another reason for
prompt diagnosis and aggressive treatment.
The encouragement of pharmacologic treatment of insomnia is welcome, inasmuch
as there are now many very effective sedative/hypnotic agents available. The
tendency has existed to prescribe ineffective or potentially more toxic agents owing
to exaggerated and unfounded fears associated with prescribing those agents
that are truly effective. Just as physicians are comfortable prescribing long-term
stimulants for hypersomnolent conditions such as narcolepsy or idiopathic central
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