Insomnia and Pain: A Chronic Cycle

Wake up to the benefits of cognitive behavioral therapy and other strategies to manage your pain and improve your sleep quality.

Anyone can experience a sleepless night once in a while, but if you regularly have trouble falling asleep, staying asleep, or don’t feel rested in the morning—and you also live with pain—you may be experiencing a double setback.

Insomnia is a common sleep disorder that over the long-term can negatively affect your physical and mental health. About one-third of Americans have some form of insomnia, and 10% to 15% of adults report chronic insomnia (that lasting 30 days or more) severe enough to impact their functioning the next day. Insomnia can cause daytime fatigue and can also lead to poor work performance, impaired decision-making, relationship problems, and a reduced quality of life.

The Pain and Insomnia Connection

While primary insomnia is disordered sleep that occurs without any specific cause, insomnia is often a symptom resulting from another condition, including pain, which is commonly referred to as secondary insomnia. In fact, approximately two-thirds of individuals living with chronic pain have insomnia. Indeed, researchers recently demonstrated that short-term sleep deprivation amplifies pain reactivity in the brain and lowers pain thresholds; even modest nightly changes in sleep quality, they argue, determine consequential day-to-day changes in experienced pain. 

This impact can go both ways: for women, for example, research suggests that those with sleep problems like insomnia are at an increased risk of developing fibromyalgia, a condition that causes musculoskeletal pain.

Wake up to the benefits of cognitive behavioral therapy and other strategies to manage your pain and improve your sleep quality. (Source: 123RF)

“A metaphor I like to use is that sleep and insomnia are hooked together like a horse and buggy,” explains Kern A. Olson, PhD, a pain psychologist and PPM Editorial Advisor who recently published the book It Hurts: A Practical Guide to Pain Management. He points out that pain can interfere with a person’s ability to fall asleep, can cause him or her to waken during the night, and can reduce overall sleep quality. “If you aren’t sleeping, it will make your pain worse,” he says. This increased pain can then further impact sleep quality, creating a cycle that can be difficult to break.

How Pain Impacts the Sleep Stages

A “normal” night’s sleep is a combination of both non-REM (non-rapid eye movement) and REM (rapid eye movement) phases, which alternate throughout the night. Within non-REM, three stages occur, beginning with light sleep that progressively deepens.

In REM, Stage 4 sleep, or “active” sleep, occurs, which allows for the growth and stimulation of muscles and tissues. Essentially, your body works to repair and restore itself while you sleep. In addition, the immune system kicks in and your body naturally stores energy to get you through the next day. Dreaming and problem-solving can occur as well. This makes REM very important for one’s well being, stresses Dr. Olson. And yet, people with pain often miss this restorative stage.

“I’ve conducted a lot of sleep studies, and people with pain get into Stage 1 and Stage 2 sleep, but they don’t get into the deeper, restorative sleep,” Dr. Olson says. “They may roll over and wake up and when they fall back asleep, they don’t fall back into whatever stage they had been in. They go back to stage 1 again,” he says. This can cause daytime fatigue, which is an additional stressor on the system, and can make pain feel even worse.

Researchers from the University of Warwick in England created the Pain-Related Beliefs and Attitudes about Sleep (PBAS) scale to measure pain patients’ attitudes on the sleep-pain connection. Interestingly, their findings revealed that when people had negative thoughts about how their pain would impact their sleep, insomnia increased. Furthermore, the scientists discovered that recognizing negative thinking and addressing it, such as through cognitive behavioral therapy (CBT), led to improvements on people’s PBAS ratings (read more about what CBT involves below).

Treating Insomnia and Pain

When pain and insomnia are impacting your life, it’s important to speak with a healthcare provider—this may be your primary doctor, a psychologist, or a pain specialist. The good news is that, with the expertise of a knowledgeable caregiver, experts estimate that approximately 75% of chronic insomnia can be addressed successfully.

One of the first things your physician will want to consider is whether any of the medications you’re taking could be compromising your sleep quality. For instance, opioid pain medications and short-term sleep aids can prevent you from getting into that much-needed REM stage of sleep. Once your physician has assessed your situation, he or she may suggest taking a different pharmacological approach, a behavioral approach, or a combination of both.

Pharmacological Options

  • Hypnotic medications: Commonly referred to as sleeping pills or sleeping aids, hypnotic medications are a common option to treat insomnia. Hypnotic medications can fall into two classes: benzodiazepines and non-benzodiazepines. Both types of medications can cause an array of side effects, making their usage controversial. Dr. Olson points out that sleep aids can, in fact, negatively impact REM sleep, which can be detrimental.
  • Tricyclic antidepressants: These medications have been used for decades to provide a sedating effect and can help sleep. “These can be great pharmaceutical sleep aids when used in very low doses,” Dr. Olson says. “Early research suggests that they do not influence sleep at the ratio of REM/NREM,” he says, making them a favorable option.

Non-Pharmacological Options

There has been increasing recognition recently of the benefits of using non-pharmaceutical options to treat insomnia and pain without the side effects of pharmaceuticals. “Sleep is a natural state. If you can achieve it by natural (non-pharmaceutical) means, you’re better off—both for your health and to give you a sense of being in control,” Dr. Olson says.

  • Cognitive Behavioral Therapy (CBT): CBT is a highly effective form of short-term psychotherapy that focuses on using both cognitive and behavioral strategies (addressing thought patterns, reframing them, and addressing actions that impact sleep). The approach provides people with an important sense of control over their situation, and can help to reduce pain and related insomnia. Better yet, the benefits typically extend after the treatment ends. Clinical trials have found that people with pain who try CBT experience positive, long-term results. (See more on how to get your sleep back with a CBT approach).
  • Relaxation Techniques: Deep-breathing exercises, mindfulness meditation, and guided imagery can provide relaxation to help people with pain manage their breathing, heart rate, and mood to get into a more relaxed state before bedtime. A trained doctor or therapist can help you learn how to use these techniques to improve your sleep experience. Relaxation techniques are typically used in conjunction with CBT.
  • Cranial Electrotherapy Stimulation (CES): There has been a growing reliance on the use of a device called the Alpha-Stim CES to treat insomnia in patients with pain from fibromyalgia and other conditions, according to Daniel L. Kirsch, PhD, DAAIPM, neurobiologist and president of the American Institute of Stress, as well as a PPM Editorial Advisor. Dr. Kirsch explains that this device works by stimulating the production of important chemicals in the brain that control mood and sleep. In some clinical trials, sleep time was significantly increased using the device. “There [were] no significant side effects, no addiction, no tolerance, and no polypharmacy effects. It is a lot cheaper to use one device to treat multiple symptoms than several medications,” Dr. Kirsch says.

Other Strategies to Improve Sleep and Pain

In addition to using the approaches noted above to manage your pain and insomnia, Drs. Olson and Kirsch agree that there are a number of things people can do at home to improve their sleep quality as well, including:

  • Practicing good sleep hygiene. This means going to bed at the same time every night, avoiding electronics in the bedroom (especially before bedtime), creating a relaxed setting in the bedroom, limiting naps during the day, not eating dinner too late into the night, and engaging in a regular exercise routine.
  • Paying attention to physical signs. Dr. Olson suggests paying attention to signs from your nervous system. When you have pain, it can constrict blood flow and cause your hands and/or feet to be cold, which is a sign that you may not yet be ready to sleep.
  • Engaging in exercise. Exercising regularly or staying physically active can help your body tire during bedtime.

By acknowledging one’s pain and insomnia connection, and taking the necessary steps toward addressing it, you can improve your sleep quality and wake up feeling refreshed in the morning, ready to take on the day!

Updated on: 08/02/19
Continue Reading:
Living with Pain? Here’s Why Sleep is So Important and How CBT Can Help