Have you ever had a series of nights with broken sleep? It seems OK on the first night, and most of us can function adequately that next day, but if it goes on, and on, and on – and on… then life starts to take on a negative hue and even little things can feel pretty daunting.
Over the weekend I took a trip to see my son, necessitating two nights so-called sleep in a hotel. It was a nice hotel, lovely bed, warm, and I even had wonderful pillows – but not a lot of sleep because right outside the window was a main road, down which noisy party-goers and rowdy cars and trucks and buses passed all night. To top it off, there was a crash outside my window with sirens and flashy lights and – well, you get my point! Not so bad on the first night, but the second and my patience was wearing a little thin.
For many of the people attending for pain management, sleep disruption is ‘normal’. Part of the problem is the nature of our sleep architecture – periodic changes in the sleep ‘depth’ leave us a bit vulnerable to waking (such as just before or just after a period of REM sleep), and if there is something like a noise, discomfort (full bladder, painful hip, stuffy nose), then we’re much more likely to rouse fully and be aware of waking up when normally we’d roll over and go back to sleep without knowing that we’d been awake. Part of the problem too, is that for many people with chronic pain, medications (and/or the use of alcohol or marijuana) can increase our drowsiness, making it easy to fall asleep – but not so easy to remain asleep, or to fall back to sleep once they’ve woken up.
We also know that after a few days without good sleep, we can get cranky. Life doesn’t seem quite so nice! Sleep disruption is often a feature of mood disorders and anxiety – and many people with persistent pain have co-occurring mood problems. Combine low mood with poor sleep – and we know the outcome is increased pain on the days following a poor night’s sleep, and after a day of increased pain, the following night’s sleep is often poor as well.
Helping people develop good sleep patterns is a common part of pain management. Simple sleep hygiene habits (like this) are often included in pain management programmes. Relaxation strategies are also often part of pain management. Including relaxation training in sleep management can help people counter their increased arousal levels if they wake during the night, but can also help people fall asleep in the first place, making the use of hypnotics, alcohol and other drugs less necessary. A recent study of CBT treatment for insomnia found that it is highly effective, even when delivered in a group format.
The role of negative mood in the sleep-pain relationship is not well understood. The relationship between sleep disturbance and negative mood is well-established, with sleep problems being listed as a symptom of both major depression and anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders-IV, Text Revision.
Increased negative mood has been found to increase perceptions of a period after pain. (O’Brien, Waxenburg, Atcheson et al. 2010)
The study I’ve cited today found some interesting features – people with different types of pain have different types of sleep problem. People with fibromyalgia and low back pain had poorer sleep than those with facial pain. The differences weren’t so much in terms of type of sleep disturbance, but in terms of how much sleep was lost.
Poor sleep lead directly to lower mood, and to higher pain, but when low mood was used as a mediator, it was found to mediate the relationship between sleep and pain.
What this means for us as clinicians is that it may be helpful to address both sleep hygiene – and low mood – and that either or both may influence pain.
This study found that negative mood may influence pain intensity via poor sleep – meaning that if negative affect is addressed, it may have an influence on pain indirectly.
It also suggests that as therapists we may need to move beyond simple sleep hygiene practices. ‘ Sleep restriction temporarily reduces an individual’s time in bed to be consistent with the amount of time that they report actually sleeping (typically via sleep diaries). This reduces the amount of time spent awake in bed and may also result in individuals’ developing a
temporary sleep debt, which primes homeostatic mechanisms to promote sleep.’
More on this strategy later this week!
O’Brien EM, Waxenberg LB, Atchison JW, Gremillion HA, Staud RM, McCrae CS, & Robinson ME (2010). Negative mood mediates the effect of poor sleep on pain among chronic pain patients. The Clinical journal of pain, 26 (4), 310-9 PMID: 20393266
Spielman AJ, Saskin P, Thorpy MJ. Treatment of chronic insomnia by restriction of time in bed. Sleep. 1987;10:45–56.