Understanding Insomnia: Jack Edinger, PhD

Pioneering researcher Jack Edinger, PhD, is honored for his service discerning the nature, classification, and management of a common sleep disorder characterized by a lack of ability to fall or stay asleep.

Edinger Will Harner

Edinger and Will Harnar review a sleep study at National Jewish Health in Denver.

It started as a typical midweek morning when the message from the American Academy of Sleep Medicine (AASM) arrived in the inbox of Jack Edinger, PhD. The AASM told the pioneering insomnia researcher that he had won the 2018 Nathaniel Kleitman Distinguished Service Award.

“I was in my Wednesday clinic, getting ready to see my patients, and when I opened up my email, I almost fell out of my chair!” Edinger, a professor and insomnia specialist at National Jewish Health (NJH) in Denver, tells Sleep Review in a phone interview. “It’s overwhelming, really. When you look at the list of people who were given this award before me, it’s really humbling.”

Edinger—whose lifetime of research includes an early randomized controlled trial on cognitive behavioral therapy for insomnia1—has spent decades volunteering on AASM committees, participating in workgroups, and leading task forces developing diagnostic systems for insomnia.

The AASM email read, in part: “The Board of Directors greatly appreciates the many contributions that you have made to the AASM, including your service as chair of the Nosology Committee, member of the Presidential Committee on Behavioral Sleep Medicine, member of the International Classification of Sleep Disorders (ICSD) Revision Task Force, and frequent course lecturer. You also have made a lasting, positive impact on the field of sleep medicine through your research and clinical work devoted to the nature, classification, and management of insomnia disorders.”

Edinger also headed AASM’s Research Diagnostic Criteria for Insomnia Workgroup and currently is leading the academy’s Insomnia Treatment Guidelines Task Force. He will receive the prestigious award at the SLEEP 2018 meeting, to be held June 2-6 in Baltimore.

“The academy has given me so many opportunities to work toward something like this that I guess I really could have only blown it,” jokes Edinger, who prior to joining NJH spent more than 34 years in North Carolina as a clinical psychologist at the Durham VA Medical Center, which is affiliated with Duke University, where he remains an adjunct professor.

“Things like this are never about one person,” he quickly adds in a more serious tone, betraying his genuine fondness for the students he’s taught and friends he has made in sleep medicine. “The sorts of accomplishments [AASM] cited in the letter are all things that I did not do all by myself, but with a lot of my very competent colleagues and friends that I have made in the field over the years. That fact is not lost on me. And when I get the award, it certainly will be mentioned.”

Identifying Phenotypes

Edinger Office

Edinger working in his office at NJH.

The dozens of studies and influential publications on the behavioral therapy side of insomnia research that Edinger has authored and co-written with colleagues over decades dovetail with his prolific service work focused on the diagnostic side of the sleep disorder.

As chair of the insomnia sections of the ICSD-2 and ICSD-3, for example, Edinger led a task force that defined criteria and categories of subtypes, or phenotypes, for insomnia diagnostic systems. He also was involved in developing quality metrics for the evaluation and management of the sleep disorder.

“The problem we have always had with insomnia is we don’t really have any sort of biological or objective assay for diagnosing it. For example, if you are going to diagnose sleep apnea, you do an overnight sleep study, and there are particular respiratory markers that are diagnostic of that disease. We don’t have that with insomnia,” Edinger says. “As a result, we have had to base our classification system almost exclusively on interview-based data, which are notoriously unreliable from one clinician to the next. So that has really been the struggle.

“And I think when we moved from the ICSD-2 to the ICSD-3, or from DSM-IV [Diagnostic and Statistical Manual of Mental Disorders] to DSM-V, which is kind of the same move, it involved a lot of retrenching and acknowledgment of the fact that we don’t really understand the pathophysiology of insomnia all that well, and how to subtype, and that we don’t have an assay to do that.” Some of the most exciting work toward a possible diagnostic assay for insomnia, Edinger says, is by a group at Penn State led by Alex Vgontzas, PhD, that is looking at objective short sleep duration (OSSD) as a marker of a more severe insomnia subtype subject to significant comorbid illness. Edinger is currently collaborating with Vgontzas and other researchers on a grant looking at differential treatment for patients with OSSD.

“What the data has suggested so far is that they are at greater risk for disease processes like cardiometabolic disorders, hypertension, diabetes, neurocognitive deficits, and depression,” Edinger says. “While those kinds of data have not yet led to a phenotyping system for insomnia that could be integrated into diagnostic manuals, I do think it has promise for that in the future.”

Carrying It Forward

Edinger Patient Notes

Edinger and Avery Soderberg review patient notes in Edinger’s office.

Sleep medicine was not recognized as a medical subspecialty until the 1970s, but psychologists have always had “a respectable seat at the table,” Edinger says. “One of the things I have always appreciated is that sleep medicine truly is a multidisciplinary field.”

He points to the late Richard Bootzin, PhD, and Peter Hauri, PhD, as two of his role models. “They blazed the trail for psychologists in the field and gave us models to follow that, combined with a confluence of other factors, allowed somebody like me to get into this position,” he says.

Edinger is grateful to have worked with and befriended the preeminent sleep medicine researchers, both of whom passed away in recent years. One thing that piqued Edinger’s initial interest in sleep medicine was early writings on insomnia by Bootzin, with whom he developed a “warm friendship,” collaborating on a number of workgroups, co-authoring publications, and more. And Hauri was chair of the ICSD-2 task force and recruited him to chair the insomnia section.

“Very early in my career, I had a patient, a veteran, who was having migraines. So I started doing some biofeedback treatment with him. Then during one of his visits, he mentioned he also had insomnia,” Edinger recalls. “I had just read a chapter that Dick Bootzin wrote about how to treat insomnia with stimulus control therapy. I had never used it before, but it looked pretty straightforward, and his writing was very clear and easy to follow, so I tried it with this particular patient. And when he came back a few weeks later, although he was still having the headaches, he was sleeping like a champ! That really got my attention.”

Edinger’s joint appointment at the VA and Duke allowed him to develop clinical activities and do insomnia research. He would cofound an insomnia outpatient program with colleagues and was instrumental in establishing a sleep lab at Duke in the 1980s.

“We published some of the first case studies using cognitive behavioral therapy (CBT) for the treatment for insomnia,” says Edinger, who credits then-chair of the psychology department at Duke, Bernard Carroll, PhD, for encouraging him to seek government funding for his research, resulting in Edinger’s first National Institutes of Health grant. “It actually took me five tries!” he says. The results of the study were published in JAMA and showed CBT was more effective at treating insomnia than a relaxation technique popular at the time.1

“The other thing I would tell you is that I have had the really good luck to have had a number of great students who worked with me over the years, as post-docs and so forth,” Edinger adds. “And honestly, they’ve probably taught me as much as I have taught them.”

What the Doctor Ordered

Edinger grew up in Lehighton, Pa, a small town in the Poconos, where his father worked in insurance and his mother at the local high school. While he knew getting a college degree was wise, he had no definitive plans about what to study when he got there.

“I sort of stumbled into the psychology program at my college,” he says.” It seemed very logical, all of the premises, and science just made sense to me.” An undergrad degree at Lafayette College in Easton, Pa, preceded a PhD in psychology from Virginia Commonwealth University in Richmond.

Edinger was lead psychologist for about 14 years of his more than three decades with the VA, when, at age 60, he decided to retire. That wouldn’t last long, however. Colleagues who were aware NJH was interested in adding an insomnia treatment program began encouraging him to move to Denver to run it.

“One might think that going to a new place and starting entirely over, and having to build things up from scratch again at age 60, is kind of like being out of your mind. And sometimes I thought that to myself,” he says. “But, you know, it was probably the kind of job that I always wanted. I am 100% in the sleep program here; that’s all I do. I don’t have any administrative responsibilities. I just have responsibilities of running the behavioral sleep medicine clinic and developing a funded research program, which I’ve been able to do in the six years I have been here.”

How long does Edinger think he will continue working?

“I don’t know. I still really enjoy it. But I do have competing factors that make me want—and probably do need—to think about retirement,” Edinger says, referring to his toddler son who lives in Spain with his mother, who is faculty at a university in Murcia, her hometown. “We just bought a house there together….And, of course, I am trying to get over there as much as I can. But you can’t just tell your patients, ‘Well, I will see you in three months. Have a good life.’”
Edinger is actively recruiting a junior person to eventually take over his clinical work and generate funding for research, “but they’re hard to find,” he says, then admits, “plus, I still really like the work.”

Friends in Deed

Edinger Sleepio

Edinger demonstrates how Sleepio software provides customized advice to patients with insomnia.

While Edinger may have been shocked at learning he’d won the AASM award for his distinguished service work, few others in sleep medicine likely would have been.

“Dr Jack Edinger is clearly one of the most important clinician-scientist-educators in sleep medicine,” says James K. Wyatt, PhD, DABSM, FAASM, director of the Section of Sleep Disorders and Sleep-Wake Research at Rush University Medical Center in Chicago.

In 2011, Wyatt contributed to an Edinger-led study that tested the reliability of insomnia diagnoses listed in the DSM-IV-TR and the ICSD-2. The landmark article on the results would lead to the changes and improvements to the diagnostic accuracy seen in the later editions of both.2

Edinger’s “track record of methodical, creative, and important research publications has been critical to enabling the practice of evidence-based sleep medicine. He has worked tirelessly to educate sleep scientists and clinicians from across the globe. His leadership and research transformed how we diagnose and conceptualize the insomnia disorders,” Wyatt says.

Longtime colleague and good friend, Colleen Carney, PhD, CPsych, director of the Sleep and Depression Laboratory at Ryerson University in Toronto, and author of nine books on insomnia, adds, “Jack Edinger has had an immense influence on my work. During my time at Duke, he was generous with his time and expertise. He taught me how to write grants, how to be productive, and how to contribute effectively as part of a large interdisciplinary clinical team. He also taught me how to grow vegetables, install an above-ground pool, and construct a good NCAA tournament bracket.

“It’s difficult to conjure a more influential figure in modern day behavioral sleep medicine. When there is leadership needed, Jack is the one who is asked because his expertise is above all others. But he is also a down-in-the-trenches leader who people respect and will gladly serve under. It’s hard to imagine someone more deserving of this honor.”

Colin Espie, PhD, DSc, FRSM, FBPsS, a Scottish neuroscience professor at the University of Oxford in England, echoes his colleagues’ sentiments. “Jack Edinger is one of the foremost sleep researchers of his generation. He has been hugely influential in helping us consider what the disorder of insomnia is, how to evaluate it thoroughly, and how to implement psychological therapies efficiently as well as effectively,” he says.

Edinger is currently using software Espie developed called “Sleepio” for a CBT study of the treatment of patients with insomnia and sleep apnea. Sleepio features an animated therapist who responds to individual patient needs using sophisticated algorithms. It is designed to disseminate CBT to patients in sleep labs without a mental health expert on staff. “It’s pretty amazing stuff,” Edinger says.

The world-renowned pair of sleep researchers became fast friends decades ago, and Espie offers this anecdote about his good friend: “Jack is an extreme morning type who likes to eat dinner very early and head to bed around 9 pm. Some years ago, when he was at Duke, he visited me in Scotland and was noticeably the life and soul of the party right through to midnight and beyond. Of course, he had the benefit of a five-hour time lag! Oh well, at least he was ‘normal’ for almost a week.”

With colleagues across continents and time zones, Edinger says he is thankful for the experiences and opportunities a career in sleep medicine has afforded him. He says, “I have had the great luck of having a large number of very enjoyable colleagues all over the country, and around the world actually, to work with over the years. And the people in insomnia are almost unerringly very nice people. It’s been a fabulous ride. I can’t think of anything I would have rather done.”

Chuck Holt is a Florida-based freelance writer and editor.

References

1. Edinger JD, Wohlgemuth WK, Radtke RA, et al. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. JAMA. 2001;285(14):1856-64.
2. Edinger JD, Wyatt JK, Stepanski EJ, et al. Testing the reliability and validity of DSM-IV-TR and ICSD-2 insomnia diagnoses. Results of a multitrait-multimethod analysis. Arch Gen Psychiatry. 2011 Oct;68(10):992-1002.

from Sleep Review http://www.sleepreviewmag.com/2018/05/insomnia-edinger/

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