Consider the following case. A 49-year-old man who has “never been a great sleeper” presents with a 2-year history of persistent trouble falling and staying asleep, daytime lethargy, and irritability. In a car accident 2 years ago, he sustained a back injury and a minor closed head injury with loss of consciousness for less than 1 minute. Past medical history includes dysthymic disorder and mild adult-onset diabetes mellitus. Previous work-ups revealed a mild peripheral neuropathy, probably secondary to diabetes, chronic rumination, and an unspecified personality disorder. On neuropsychological testing, a mild cognitive dysfunction was found. There have been no positive findings on either electroencephalogram (EEG), CT scan of the head and back, or radiograph of the spine. Current medications include intermittent use of cyclobenzaprine HCl, ibuprofen, and diazepam for back pain and diazepam for sleep.

The graphic diary called a sleep log (Figure 1) was filled out for 1 week prior to the consultation. This log confirms the presenting complaint of trouble falling and staying asleep. An acute back spasm on Tuesday evening was treated with drugs and bed rest and remitted after 2 days. The differential diagnosis of the sleep disturbance includes insomnia associated with postconcussive syndrome (mild traumatic brain injury), myofacial pain, and drug dependency. The possible role of a number of additional entities needs to be considered, however. The patient's chronic depression and ruminative cognitive style may have predisposed him to develop an insomnia. The peripheral neuropathy suggests that one of the causes of awakenings may be periodic limb movements. The sleep log may have alerted the clinician to the patient's napping at different times of the day and the irregular timing of retiring and arising as factors that may be perpetuating the insomnia. Finally, the patient's practice of spending time lounging and resting in bed, as well as the excessive time trying to sleep (significantly more than 10 hours in bed), may have become conditioned habits that are sustaining the problem.

This case illustrates the many factors that potentially play a role in insomnia. In the authors' view, challenging cases such as this one will yield to a treatment plan based on a comprehensive evaluation and consideration of predisposing, precipitating, and perpetuating factors. Following a review of the assessment of insomnia, this article returns to case material to introduce treatment strategies. The format of the final section is designed to encourage the reader to participate in the clinical endeavor. It is the authors' contention that with the help of a sleep log, the clinician with little formal training in sleep disorders can evaluate and treat the often difficult cases of chronic insomnia successfully.