Oh… to sleep – CBT for insomnia in chronic pain

There are very few people who have chronic pain who have sweet dreams all night and wake feeling refreshed – having disturbed sleep and waking feeling grouchy seems to come with the territory for so many of the people I’ve seen with chronic pain! If it’s not difficulty staying asleep, it’s difficulty getting off to sleep, and if it’s not that, it’s feeling like the sleep that has been had simply isn’t good enough. So to find an effective approach to managing sleep problems without medication sounds a bit like a Holy Grail.  There is good reason to ensure restful sleep – studies show that poor sleep increases pain the following day, while a high pain day increases the risk of even poorer sleep that night.

And yes, there is a way to treat sleep problems in chronic pain without medication – but there is a downside, as always – it’s quite hard work!

Cognitive-behavioral therapy for insomnia (CBT-I) is a well-established approach for helping people return to a refreshing sleep pattern.  It involves several strategies including:

  • sleep restriction,
  • stimulus control,
  • sleep hygiene,
  • cognitive therapy devoted to catastrophic thoughts about the consequences of insomnia

Sleep restriction refers to restricting the amount of time spent in bed overall, and can mean reducing the amount of time attempting to sleep.  For example, if a person hasn’t been falling asleep until after midnight, and has fairly disrupted sleep with several wakenings during the night, maybe achieving 5 hours sleep in total, sleep restriction would mean not even attempting to go to bed until five hours before he or she wants to wake up.  Needless to say this can be pretty challenging for the person!

Stimulus control includes removing things like the clock from the room (too easy to keep looking at the clock and counting the hours awake), staying out of bed if not asleep, taking the radio and TV out of the room and using bed for sleep and sex and nothing else.

Sleep hygiene includes the above, but also introduces things like avoiding coffee or other stimulants before bed, keeping the room temperature warm-but-not-hot, exercising in the afternoon rather than late, avoiding eating in bed or during the night and so on.  Relaxation techniques and other soothing strategies are also included.

Finally, cognitive therapy for catastrophic thoughts about not sleeping is used to reduce that sinking feeling about lying awake ‘all night’ and thinking ‘I’ll never cope with the coming day’.  Some of the thought challenging that can be used here involves recognising that it’s actually possible to keep going on very little sleep; that while carrying out things like sleep restriction it’s no worse than having insomnia; and using positive statements like ‘it’s only for a while’ and ‘if I just take it easy over the day I’ll get through’.

Jungquist and colleagues conducted CBT-I for people with chronic pain in the study I’ve referred to today.  Now while this is a small group of people, this is a group of people with chronic pain – most of the previous studies on CBT-I have been with people who have primary insomnia, or insomnia that is not associated with another medical problem.  People with chronic pain often attribute their poor sleep to their pain, rather than any other factors, so it’s interesting that pain intensity didn’t change, although the interference of their pain on everyday life (as measured by the MPI, Multidimensional Pain Inventory) did improve.

This study protocol used an eight-week programme covering the strategies I’ve described above, and I’m immediately jealous because it’s common for me to see people for 12 weeks (once a week) to cover not only poor sleep, but also activity management, understanding chronic pain, developing relaxation responses, communication etc etc!  8 sessions are not a lot of sessions, and by comparison with the short-term effects of taking medication, these skills will last a lifetime.

While this study clearly demonstrates that CBT-I is an effective approach for people with chronic pain who also have the common symptom of poor sleep, I wonder whether this will influence the GP or pain physician tendency to prescribe sleep medication.  Taking a medication is a mixed blessing – some people with chronic pain prefer to take a pill because it’s easy, quick, acts fast, and is a known entity.  It’s also not a ‘psychological’ treatment.  Other people don’t like medications because of fears that it will lead to addiction, disliking side effects, the need to remain alert at times during the night because of children, or because medications can be ineffective.

I have seen that if a simple, quick and easily taken medication is available concurrent with a difficult, long-term, self-managed approach, it’s more probable that the person will take the pill in a high-risk or set-back situation.  Self management is not the easy way!

Self management through CBT-I doesn’t have to be carried out by clinical psychologists.  Suitably trained and experienced clinicians of many persuasions including, as in this study, nurses, but also occupational therapists, social workers, physiotherapists and others can deliver CBT-I to people with chronic pain.  It’s now more a case of GP’s and patients recognising that a non-drug approach is effective, and making sure funding agencies support delivery of this type of treatment.  At the very least it should be provided with the same amount of enthusiasm and support as medication for insomnia.

Jungquist CR, O’Brien C, Matteson-Rusby S, Smith MT, Pigeon WR, Xia Y, Lu N, & Perlis ML (2010). The efficacy of cognitive-behavioral therapy for insomnia in patients with chronic pain. Sleep medicine, 11 (3), 302-9 PMID: 20133188


  1. Even though CBT for insomnia is effective, it really depends on the circumstances. I suffer from chronic pain, so my sleep was not great to start with, and then it was disordered even worse when I experienced acute insomnia as a side effect of one of my prescription medications.

    I managed to get the situation under control, but I ended up learning some CBT techniques and supplementing with medication. I am right now in the situation where I expect to have 1 bad night a week on average, and take a sleeping pill once every 2-3 weeks (so not every time I am experiencing problems). My major issue with CBT was the way catastrophic thoughts were approached. There seemed to be no room for flexibility, at least with the program I was on. And the advice I got was exactly that – modify my thoughts to think that I can get through the day even on a little sleep.

    I found this extremely frustrating, and in fact it caused me to drop the program. The truth is, in practice there are days when I can get through on very little sleep, doing tasks at work which do not require concentration. I keep a backup plan for tasks that I can accomplish on bad pain or bad sleep days. But there are many days when having too little sleep brought serious negative consequences – important meetings which could not be re-scheduled, and which didn’t accomplish the goals because I could not concentrate; doctor’s appointments when I forgot to ask crucial questions (even after writing them down) because I could not process information quickly enough and keep track of what was being said.

    So I have taken some things from CBT – good sleep hygiene, a relaxation exercise – but then settled on supplementing with sleeping pills because I felt that the expectations were unrealistic for someone like me, trying to maintain a regular job.

    1. I can understand the frustration of not being able to persist with a challenging programme when you’re concurrently trying to carry out difficult daily tasks! And it looks like you’ve arrived at a place where you are feeling reasonably OK with your results.

      I wonder what your mind might have said to the thought: ‘If I can get through this programme for 12 weeks on just a little sleep, even though it’s hardI know things are going to get better., I’ve probably been ‘getting by’ on less sleep than this over the past [X] years, so I know I can cope on very little sleep – and I’ll let people know that I’m trying something new so they can make some allowances over the next couple of weeks.’

      Maybe now is a good time to consider having another attempt at using the sleep restriction and CBT strategies, while things are a little more settled? The strategies are still there for you, and you might find it easier to put them in place now that the effects of the medication that wired you up have gone.

      At the very least, you’ve picked up some effective strategies that are helping you feel more able to manage your unrefreshing sleep, and that’s a good thing.

      1. I think this perhaps was the difference. I could go ahead with “It will be difficult for 12 weeks, but I will do sleep restriction and other CBT techniques, and see if I can get an overall improvement”. In fact, what worked for me in the end was “It will be difficult to not take sleeping pills regularly, but I will commit to a CD relaxation program for 12 weeks and see if I can normalize my sleep”. But this was suggested by my regular GP, after I told her that the CBT program was not working out. In contrast, the CBT program (which was mostly a book-based program with little one-to-one time, to be honest) seemed to be about “In addition to sleep restriction, we will teach you skills to apply regularly. Don’t ever think that if you have difficulty concentrating at work because of lack of sleep, consider all the other possibilities instead, maybe you are just bored”.

        For me, there is a huge difference between “it can present additional difficulties for a while, but I have been getting on with unrefreshing sleep for a long time, so I will try something for 12 weeks and see if I can get better results for a long term” and “I have to change my thinking permanently and talk myself into disregarding negative effects lack of sleep has, in order to make myself less anxious”. Possibly this was just “bad chemistry” between me and the particular CBT program, but this is what I perceived and could not cope with.

      2. What a shame this programme doesn’t seem to have looked at what your particular concerns were with coping with the sleep problem. If you still have the book, now might be a nice time to re-look at it, and see whether there is anything you would like to put in place now. Of course, if you’re happy with occasionally using medications, that’s fine too 🙂

        It’s funny, in a way, but right now I’m having a couple of nights of disrupted sleep – what’s helping me is using my relaxation, getting out of bed when I haven’t been asleep for more than 20 minutes, and reminding myself that it will settle down provided I stick with the effective habits. That last one is the cognitive part – and it’s important so that I don’t start down the worry trail…!
        I do agree, there is a huge difference between feeling OK about short-term concerns to give the long-term benefits a chance to settle, and feeling like you have to ignore the very real effects of poor sleep, or pretend they don’t happen!

        One thing I value is using self-talk honestly – trying to fool yourself that what you’re saying is true when it isn’t, doesn’t seem to help much! So I prefer to think of ‘helpful’ vs ‘unhelpful’ thinking, and to use helpful and coping thoughts when things are challenging, rather than trying to argue my way out of acknowledging what I am experiencing. Of course, sometimes I’m ONLY seeing the negative, but even then, using a helpful way of viewing my situation makes a bit difference to how much I persevere!

      3. I really like this perspective! Of course, the book said “don’t pick and choose, you have to do it all”. But since I ended up picking and choosing anyway, I think I could go back and see if more skills would be of use. The perspective of “It will get better if I stick with effective habits” makes a lot of sense for me.

        What you said about helpful vs. unhelpful thoughts also reminded me about another bit of research I read. Can’t track the paper down quickly, but the gist was that “positive affirmations” (often recommended in various self-help books) weren’t helpful for people with low self-esteem. It seemed that people who tried to talk themselves into what they didn’t truly believe were mostly making things worse for themselves rather than better.

        I guess there are lots of variables within each program, how it is delivered, etc. But that’s why research is so important to figure out what truly works!

      4. …and why therapy isn’t a ‘cookbook’ or recipe approach – it’s about a therapeutic relationship, developing a set of hypotheses about what ‘might’ be going on, and doing therapy to confirm or disconfirm the hypotheses. Good luck with rereading, you never know what might make sense now.

        I think if you don’t believe what you tell yourself then you might end up making those negative beliefs stronger – I think of the situation in ‘pushing’ a person to, say, stop smoking. If you move too far ahead of where the person is at, they end up giving you more and more reasons NOT to change. The Motivational Interviewing approach instead looks at ‘rolling’ with expressions of the benefits of the current situation by empathising – then asking the person to identify what is ‘not so good’ about not making any changes. By doing this, the person comes up with their own reasons for making a change, because they ‘own’ them.
        Similarly, if we can find an alternative but helpful way of viewing a situation, that is also true, then we’re probably going to be able to say it and ‘own’ it.
        Maybe it’s time for me to post some more on this!
        thanks for a great discussion and good luck!

  2. How can you possibly be sure that the effects of CBT-i will last a lifetime. It seems to me it only lasts if people continue using the skills. Part of the problem as I see it is that things change and the skills aren’t usually reinforced periodically.

    1. OK, you’re right Esther – the skills are there, but if they’re not used, they’ll fail. What I meant to say was that the skills, once learned, are always there to be used – whether they are or not remains up to the person! Reinforcing use of skills is something that I think a GP or practice nurse could do perhaps as part of a usual health review.

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