I have written about sleep problems in people with chronic pain several times. It is one of those aspects of dealing with pain that inevitably arise as I talk with people about energy, their activity through the day, and their mood. Many people blame the pain for their sleep problems, which is unsurprising really – once you’re awake in the middle of the night, there’s not a lot else to think about! But it seems like while pain might be associated with a sense of poorer quality sleep, and could well have been a factor influencing the onset of insomnia, it’s often other factors that maintain unsatisfying sleep.
What are those factors? Well, one of the first ones is ‘general affective disturbance’ - in other words, feeling low or flat, whether frankly depressed or not, can lead to changes in sleep architecture. Sleep architecture refers to the patterns of brain activity that are normal and expected in people throughout their sleep. People who are depressed demonstrate shortening of the time from sleep onset to the appearance of the first REM period (short REM latency), while people with fibromyalgia show specific and distinctive abnormalities in the stage 4 deep sleep. During sleep, individuals with fibromyalgia are constantly interrupted by bursts of brain activity typical of being awake, limiting the amount of time they spend in deep sleep. It’s also thought that people with central sensitisation syndrome (such as CRPS, irritable bowel, pelvic pain, migraine etc) have similar changes to their sleep pattern - and fatigue is often a feature characterising these problems.
It’s not only disorders that affect sleep architecture: some medications and common substances also affect sleep, including alcohol, coffee and common sleeping pills.
While we can’t ‘fix’ the chronic pain condition, we can treat depression, and we can help people identify any of the substances that might alter sleep patterns.
More often than not there are other things that also contribute to maintaining poor sleep. Some studies suggest that poor sleep is maintained by the amount of attention focused on pain, the ways in which pain is interpreted (particularly sad, or irritated responses to pain), and thought patterns particularly before going to sleep (rumination or brooding on pain). These are aspects of sleep management that may not always be addressed in general pain management programmes which often provide sleep hygiene.
A thorough assessment of sleep problems is an important part of developing an appropriate management strategy. Sleep assessments in this case don’t refer to being wired up at night btw – and I’m not referring to sleep problems caused by sleep apnea or snoring.
A sleep assessment should cover things like:
- time of going to bed, and the pre-sleep rituals
- time to sleep onset, number and timings of sleep awakenings as well as the length of time awake at these times (not to mention what the person does at these times such as eating, getting out of bed, having a smoke or coffee …)
- waking time, and how refreshed the person feels at this time
- naps and timing of exercise during the day
- coffee, alcohol, tobacco and other substances taken
Now while simple sleep hygiene can be helpful for many people, there are several other strategies that have good evidence to support their use in insomnia.
These methods are all included in what is called Cognitive Behavioural Therapy for Primary Insomnia. This is described by Tang as ‘a multi-component treatment that seeks not only to teach patients about sleep and factors affecting sleep (eg homestatic regulation, circadian rhythm, age, social and work schedule) but also to work with the patient toward minimisng unwanted arousal at bedtime and altering sleep habtis to increase sleep propensity and regularity. More cognitively oriented therapy involves interventions that aim to address worries and beliefs about sleep, particularly anxiety-provoking thoughts like ‘I’m losing control over my sleep’ and safety seeking behaviours (like drinking extra coffee or spending longer in bed).’
CBT-I can include psychoeducation, sleep hygiene, relaxation training, cognitive therapy, sleep restriction, stimulus control therapy, paradoxical training, biofeedback and imagery training. Of these strategies, relaxation, sleep restriction and stimulus control therapy have the most support from research as stand-alone interventions. CBT-I has been repeatedly shown to be effective for remedying insomnia, and found as effective as hypnotics in the acute treatment phase, with the benefit of providing long-term results.
Despite this positive finding, between 43% to 85% of people don’t respond to even intensive CBT-I treatment when stringent outcome criteria are applied. When Tang reviewed the content of three RCT’s for insomnia for people with chronic pain, she found that much of the content relied upon behavioural interventions – but research in other population shows that it’s just as important to address beliefs and attitudes about sleep. Maybe this is an area to focus on a little more in pain management programmes also.
Tomorrow I’ll discuss some of the cognitive strategies and especially the sort of thoughts and beliefs that people can have about sleep – but I’ll write about this after I’ve had a sleep!