Sleep and Pain: Understanding the relationship
For many people issues with sleep and pain go hand in hand. Most people have had an experience where acute pain (such as pain after an injury, a headache, or pain after a surgery) has gotten in the way of a good night’s sleep. So, when people with chronic pain mention that they have trouble sleeping due to intense pain, most people at least have a framework for understanding the experience. However, losing a few nights of quality sleep due to pain is different than experiencing poor quality sleep night after night for months or years on end; which is often the case for people who have chronic pain.
Common Challenges:
People who experience chronic pain may have any of the following challenges when it comes to sleep:
Difficulty falling asleep due to:
trouble finding a comfortable position or a position that does not make pain worse
pain keeps them awake
pain grabs their attention and then they cannot stop thinking about the pain itself, or the impact of pain on their life
Trouble staying asleep because:
pain wakes them up in the middle of the night
they need to reposition frequently throughout the night due to pain
Difficulty falling back to sleep after waking in the middle of the night due to pain, or any of the pain-related issues that can make falling asleep in the first place hard
Waking up earlier than desired due to pain or pain medications wearing off
·Difficulty waking up in the morning due to:
Stiffness/pain
Exhaustion from poor sleep during the night
Excessive sleepiness from medications (some pain medications and some sleep aids can leave you feeling extra tired in the morning)
Additionally, since pain can often interfere with your ability to achieve a good night’s sleep, people with chronic pain often experience fatigue due to lack of sleep as well. (Gebhart et al, 2017). Then you add medications into the mix and it can be even more complicated. Certain medication that are often prescribed for pain, such as opioids, anticonvulsants, and even some antidepressants, may increase tiredness and fatigue (Dimsdale et al, 2007; Zlott & Byrne, 2010). This makes people who have pain more likely to be in situations to make up for poor sleep at night and day-time fatigue by squeezing in a nap during the day; however, napping or sleeping during the day can actually make it harder to achieve quality sleep at night. It becomes a vicious cycle.
Poor sleep can make pain WORSE
It makes logical sense that pain can interfere with the ability to get a good night’s sleep, for a variety of reasons. However, did you know that lack of quality sleep can actually contribute to pain, or make existing pain worse?
Studies is the 1990s demonstrated that if you took completely healthy individuals with no history of sleep issues and deprived them of quality sleep (by disrupting their sleep at key points in their sleep cycle), that it actually led to the development of pain and lower pain thresholds (Lentz et al, 1999). Several studies since then have reported similar results, including a study published in 2019, suggested that sleep deficiency predicts new pain in older adults (Chen et al, 2019). Moreover articles which compile the results of multiple studies on this topic (called meta-analyses) have also shown that sleep problems are a better predictor of pain, than the other way around (Finan et al, 2013). On top of this, some people with specific types of pain, including diabetic neuropathy, may experience increases in pain intensity at night (Odrich et al, 2006).
This is why it’s so important to work on strategies to manage BOTH your sleep and pain. If you are having challenges with sleep and chronic pain, they just feed each other and if you only address one part of the cycle, you may end up back in the cycle sooner than you anticipated. Additionally, lack of quality sleep and living with chronic pain are both associated with an increased risk for depression (Ohayon & Schatzberg, 2010), which can also contribute to sleep disturbance and increases in pain. This just further complicates the situation. I often refer to the poor sleep, chronic pain, depression cycle as the “perfect storm” or “pain trifecta”. To learn more about how sleep and pain are related to depression click here
Luckily, there are effective ways to address sleep disturbance and its relationship with chronic pain. Cognitive Behavioral Therapy for Insomnia (CBT-I) and Cognitive Behavioral Therapy for Chronic Pain are great options with strong research support for their effectiveness. CBT-I can easily be added into pain-focused therapy (especially if you are doing CBT for Chronic Pain). Click here to learn more about therapy for disrupted sleep or pain-focused therapy through Beyond the Body Health Psychology Services, LLC, or check out the resources below.
References:
Chen, T. Y., Lee, S., Schade, M. M., Saito, Y., Chan, A., & Buxton, O. M. (2019). Longitudinal relationship between sleep deficiency and pain symptoms among community-dwelling older adults in Japan and Singapore. Sleep, 42(2), zsy219.
Dimsdale, J. E., Norman, D., DeJardin 1, D., & Wallace, M. S. (2007). The effect of opioids on sleep architecture. Journal of clinical sleep medicine, 3(01), 33-36.
Finan, P. H., Goodin, B. R., & Smith, M. T. (2013). The association of sleep and pain: an update and a path forward. The journal of pain, 14(12), 1539-1552.
Gerhart, J. I., Burns, J. W., Post, K. M., Smith, D. A., Porter, L. S., Burgess, H. J., Schuster, E., Buvanendran, A., Fras, AM., & Keefe, F. J. (2017). Relationships between sleep quality and pain-related factors for people with chronic low back pain: tests of reciprocal and time of day effects. Annals of Behavioral Medicine, 51(3), 365-375.
Lentz, M. J., Landis, C. A., Rothermel, J. S. H. A. V. E. R. J. L., & Shaver, J. L. (1999). Effects of selective slow wave sleep disruption on musculoskeletal pain and fatigue in middle aged women. The Journal of rheumatology, 26(7), 1586-1592.
Odrcich, M., Bailey, J. M., Cahill, C. M., & Gilron, I. (2006). Chronobiological characteristics of painful diabetic neuropathy and postherpetic neuralgia: diurnal pain variation and effects of analgesic therapy. Pain, 120(1-2), 207-212.
Ohayon, M. M., & Schatzberg, A. F. (2010). Chronic pain and major depressive disorder in the general population. Journal of psychiatric research, 44(7), 454-461.
Zlott, D. A., & Byrne, M. (2010). Mechanisms by which pharmacologic agents may contribute to fatigue. PM&R, 2(5), 451-455.
Learn more about Behavioral Sleep Medicine and CBT-I:
https://www.behavioralsleep.org/index.php/sbsm/what-is-behavioral-sleep-medicine
https://www.behavioralsleep.org/index.php/sbsm/community-education
