What about patients who can’t sleep? Case formulation for insomnia

Just as night follows day, so does sleep disturbance follow psychological disturbance.(Spielman and Glovinsky 1997: 133)The aim of this chapter is to outline an approach to formulating and treating insomnia, especially insomnia that is comorbid with another disorder. Every clinician knows that insomnia can occur as the sole presenting problem or as a condition that is comorbid with another psychiatric or medical disorder. In the complex comorbid cases, conceiving of insomnia as merely epiphenomenal to the comorbid disorder is unwise for two reasons. First, the evidence indicates that insomnia serves as a risk factor for, and can be causal in, the development and/or maintenance of the comorbid disorder (for reviews see Harvey 2001; McCrae and Lichstein 2001). Second, substantial evidence is accruing to suggest that insomnia that is comorbid with another psychiatric or medical disorder does not necessarily remit with the treatment of the so-called ‘primary’ disorder (Smith et al. 2005). Four brief case descriptions are presented in Table 13.1 to illustrate these points.