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Book Forum: Sleep and Dreaming   |    
Principles and Practice of Sleep Medicine, 3rd ed.
ROSALIND CARTWRIGHT, Ph.D.
Am J Psychiatry 2001;158:1545-a-1546. doi:10.1176/appi.ajp.158.9.1545-a
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Edited by Meir H. Kryger, M.D., Thomas Roth, Ph.D., and William C. Dement, M.D. Philadelphia, W.B. Saunders Co., 2000, 1,336 pp., $145.00.

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This is a big book in many ways: numerically, there are 1,336 pages and 110 chapters. It is also big in scope, covering both normal and abnormal sleep. This third edition of the major textbook for the field of sleep medicine is nearly twice the size of the original 1989 edition. As a text, it is not user friendly, not for the medical student (it is too big to fit into a book bag) and not for the practitioner looking for help in understanding a particular patient. The reader has to wait until chapter 46 to learn the names of the 84 disorders that make up the International Classification of Sleep Disorders. Nor will using the index be of much help. Try looking up Klein-Levin syndrome. There is only one paragraph, and that is ambiguous as to whether this is a diagnostic entity. There is no cross-reference to the chapter on idiopathic hypersomnia, which offers a subtyping of cases but does not include the hypersomnia called "Klein-Levin" or indicate whether this is a variant of bipolar illness. Likewise, if you look for help in understanding a patient with phase-advanced sleep disorder—good luck; you are on your own.

On the bright side, there is very good coverage of breathing affected by sleep disorders. Nineteen chapters, about 60% of the book, are devoted to the physiology, epidemiology, symptom picture, and major treatments of sleep-related disorders of respiration. Yet the novice reader is confronted with inconsistencies in both the diagnostic criteria of sleep apnea and the appropriate treatments. Most often the diagnosis is based on the number of respiratory events per hour of sleep, but this ranges from five to 15 apneas or apneas plus hypopneas. At other times the number and severity of the desaturation episodes are included, or the number of arousals from sleep. Of course, where the diagnostic line is drawn affects the epidemiologic rates of this disorder. As for the treatment, the opening statement is that either surgery or the use of cumbersome equipment are the present effective therapies. This is followed, however, by a chapter on the usefulness of oral appliances and the greater compliance with these appliances. Weight loss is mentioned as another effective treatment. There appears to be no clear consensus on the boundaries between normal and abnormal sleep-related respiration, and treatments are a matter of clinical judgment.

In contrast, insomnia, a much more common sleep problem, gets much less attention. However, the chapters on insomnia are some of the best written and most helpful of the book, although there are definition problems that make prevalence figures vary depending on how questions are asked about sleep troubles and who asks them.

For readers of this Journal, the section on Sleep in Psychiatric Disorders is rather thin, given the extensive research literature now available. One question raised is why disturbed sleep is a major depressive symptom but experimentally induced sleep deprivation is a well-known mood elevator. This is one of many paradoxes begging further attention.

In general, this book suffers from two problems common too many multiauthored texts. First, the time it takes to produce such a tome means it lags behind the research literature. This "updated" text tells little about the newer treatment trials: Does modafinil work to help the sleepy patient maintain wakefulness? Will ablation of soft palate tissue, turbinates, or the bulky tongue bring effective and lasting control of snoring and mild apnea? Is it worthwhile to check for iron deficiency in all patients with restless legs syndrome?

The second problem is that there is a good deal of overlap among the chapters, causing both redundancy and real inconsistencies. This needs a strong editorial hand for resolution. There are definitely strong and weak points to this edition. There are some excellent chapters that summarize an area of work, such as those by Segal, Bonnet, Gillin, and Drummond and the insomnia chapters. The main weak point is that the level of sophistication needed by the reader varies tremendously from chapter to chapter. There is a lot of knowledge contained in this volume, but the potential reader must beware of the daunting task of trying to master a field in which the knowledge base is "in progress" and extracting practical guidance for patient care is no piece of cake.

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