Book Review

Insomnia: A Cultural History

Insomniac

N Engl J Med 2008; 359:1412-1413September 25, 2008

Article

Insomnia: A Cultural History
By Eluned Summers-Bremner. 176 pp., illustrated. London, Reaktion Books, 2008. $29.95. ISBN: 978-1-86189-317-8

Insomniac
By Gayle Greene. 503 pp. Berkeley, University of California Press, 2008. $29.95. ISBN: 978-0-520-24630-0

In an interesting coincidence, these two books on insomnia were written not by experts in the field but by two professors in the humanities. You might then expect the books to share some common elements, but that is not the case. Insomnia is a whimsical tour of the history of how different cultures have viewed not only insomnia but also the night itself, sleep, dreams, darkness, and activities that occur in the dark. About half of Insomniac, by contrast, is a scientific overview of what is known (very little) and not known (a lot) about the causes of insomnia. The other half describes what it is like to have chronic insomnia in a narrative based primarily on the experience of the author, Gayle Greene, who has tried to cope with insomnia for her entire life.

Eluned Summers-Bremner's Insomnia covers a wide swath of territory and poetically describes what historical figures wrote or thought about insomnia. As used by the author, the word “insomnia” includes anything that might be remotely related to the night or to sleep, thus allowing for the discussion of such wide-ranging topics as the importance of the medieval French king's bed (described as the “symbol and setting of royalty”) and the ways in which darkness is related to evil.

Insomniac seeks to provide a scientific overview of why millions of people can't get enough sleep and are thus tired, fatigued, and miserable during the day. The book also takes readers inside the minds and bodies of chronic insomniacs, recounting the pain, both mental and physical, that they experience day after day. There is a third major theme: the portrayal of the researchers and physicians who make a living in the world of sleep. Greene weaves her way in and out of these three themes — the good (the insomniac), the bad (the science), and the ugly (the uncaring practitioner) — but she does so in an evenhanded and entertaining way. The weaving and bobbing may irritate some readers and cause them to wonder about the book's intended audience. Greene recognized this problem and provides guidance by telling readers early on that they should read only certain chapters if they are interested in the scientific research and others if they want to know what life is like for an insomniac. If you are a researcher, however, and want to know what “outsiders” think of you, you should read the entire book. In the first chapter, Greene tells the reader, “This is a somewhat cranky book,” and convincingly argues that her readers would also be cranky if they had not slept well for 60 years.

Insomniac was written primarily for insomniacs — to help them understand their sleep disorder, to learn ways of coping with it, and most important, to let them know they are not alone. Greene uses many case examples (paying perhaps too much attention to her own problems, which become tiresome toward the end of the book) to emphasize that many people keep their insomnia a secret because they are often blamed for their condition. When a doctor told her, “Nothing wrong with you except you can't sleep,” Greene did not know whether to laugh or cry. Insomniac is as much a defense against those who think that “sleep is for sissies” as it is a guide for the many people — 70 million in the United States — affected by chronic sleep loss.

Greene goes out of her way to praise the many sleep scientists who have made progress in unraveling the biomedical underpinnings of sleep and sleep disorders. She has great hope for the future understanding of sleep–wake mechanisms at the neurobiologic, neuroendocrine, and genetic levels. I found the presentation of sleep science very impressive and up to date. For example, her descriptions of the role of newly discovered hypothalamic orexins (hypocretins), hormones regulated by circadian clock genes, and of the effects of sleep loss on neurobehavioral performance are at a level I would expect to find in a scientific review. Greene may get a few things wrong (for example, patents do not last for 20 years once approved by the Food and Drug Administration), but all in all, she has mastered an impressive array of the diverse literature that underlies sleep research and sleep medicine.

Insomniac attacks sleep science that is based on “psychogenic explanations” and those whose research has led them to see “behavioral modification” of “weak-willed or morally deficient” people as the cure to insomnia. Having attended every meeting of the Associated Professional Sleep Societies (APSS) since 2002, Greene has heard and talked to many of the researchers in the field and has taken sides with those who are trying to understand the biologic basis of sleep and insomnia against “people working with insomnia [who] are psychologists who don't understand the biomedical underpinnings of the problem” and who repeat the same mantra meeting after meeting: It's all in your head, get over it. Chapter 4, “Sleepless in Seattle: The Conferences,” which discusses Greene's experiences at APSS meetings, is a must-read for all sleep professionals.

Although Greene has great respect for many of the leaders in the sleep-medicine community, she is at her angriest when discussing how physicians in general, and some sleep specialists, do not see insomnia as a serious medical problem. She also questions the common wisdom that no one ever died of insomnia. New clinical, epidemiologic, and animal studies linking sleep deprivation to obesity, diabetes, and cardiovascular disease are beginning to change the views of the medical profession about chronic sleep loss and its long-term consequences for health. Greene suggests an exercise for those sleep specialists who believe people could get by on less sleep if only they tried harder: go without sufficient sleep for an extended period of time and see if the personality disorders they claim to be the cause of insomnia are instead the result of insomnia.

To sum up, Summers-Bremner's book is certainly a cultural history of what has been written about sleep and the night in the past few thousand years. If you are a physician or a scientist and have time to read only one book on insomnia, you might want to learn how the subject can be treated by humanists — and in that case, Summers-Bremner's book is the one for you. If you want an in-depth overview of the patients, the physicians, and the science that are part of the contemporary culture surrounding insomnia and sleep medicine, Greene's book is the best available on the subject.

Fred W. Turek, Ph.D.
Northwestern University, Evanston, IL 60208
fturek@northwestern.edu