Patients suffering from chronic pain commonly experience insomnia and sleeping disorders. Research shows that, of those who report experiencing chronic pain (about 15% of the general U.S. population and 50% of the elderly), approximately 65% have sleep disorders, such as disrupted or non-restorative sleep. Being familiar with the psychological techniques that can improve the sleep of a patient with chronic pain is extremely important.
Pain diminishes both sleep quantity and quality
The term "insomnia" includes all types of sleeping problems, such as difficulty falling asleep, difficulty staying asleep, and awakening earlier than desired. Of all medical conditions, pain is the number one cause of insomnia. With chronic pain problems, difficulty falling asleep is one of the most prevalent types of sleep disruption. However, awakening during the night and awakening earlier than desired are also frequent problems. Research surveys of those with chronic pain problems have found that 65% report that they are awakened during the night due to pain and 62% report waking too early due to pain. In addition, many patients with chronic pain problems do not feel "refreshed" in the morning when they awaken (a sleeping problem termed "non-restorative sleep").
Pain and sleeping problems need to be treated together
A sleeping disorder associated with chronic pain should always be addressed as part of a multi-disciplinary, chronic pain treatment approach. As with any symptom of a chronic pain syndrome, one should not attempt to treat the sleep disruption in isolation without taking into account proper treatments for the chronic pain problem. Many behavioral and psychological approaches to chronic pain treatment will also help with the symptoms of sleep disorder, and one should not be too quick to rush to medication solutions for insomnia. The use of medications for sleep disruption can be effective but will not be discussed here.
This article focuses on psychological techniques for improving sleep. This assumes that the patient is receiving proper medical treatment for the pain problem and has been thoroughly evaluated for other possible medical problems that might be contributing to the sleep disorder. Some of the common medical problems associated with poor sleep include sleep apnea (a person stops breathing for about 10 seconds or has reduced airflow hundreds of times during the night), restless legs syndrome (a person has an extreme urge to move the legs usually caused by uncomfortable sensations) and other conditions. Once any medical sleep problems have been evaluated and addressed, psychological and behavioral techniques can be implemented.
As chronic pain develops, it is not uncommon for patients to develop bad habits relative to sleep hygiene without even realizing it. An example of poor sleep hygiene habits includes such things as varying the time that one goes to bed and awakens in the morning, taking long naps during the day, engaging in stressful activities such as paying bills while laying in bed, staying in bed most of the day, among other things. Psychological tips to develop good sleep hygiene habits include the following:
Do not go to bed unless sleepy. If an individual does not feel sleepy at bed time, then he/she should engage in some activity that might help to relax. This might include such things as listening to music, reading a book, or practicing some relaxation exercises. It is important to engage in some activity that is relaxing and not stimulating at bed time. Often, watching the evening news can be distracting, but certainly not relaxing.
If one is not asleep after 20 or 30 minutes, then get out of bed. It is important not to lie in bed and "try to fall asleep" for hours and hours. This simply creates a more and more stressful situation making it less likely that an individual will fall asleep. Instead, one should find something to do that will help them feel relaxed and ready to fall asleep. Often, it can be helpful to get out of bed and return to a relaxing activity such as reading a book until they once again feel sleepy. In this manner, patients are training their bodies that a bed is a place to relax towards the goal of falling asleep.
Develop rituals that help with relaxation each night before bed. Often times, it can be helpful to develop "rituals" that one completes just prior to going to bed and getting ready to fall asleep. This might include such things as taking a warm bath, having a light snack, listening to a few minutes of music, or reading. Engaging in the same ritual each evening prior to going to bed can actually train the body that it is time to fall asleep.
Try to go to bed at the same time each night and wake up at the same each morning. Going to the bed at the same time each night helps the body develop a healthy sleep-wake cycle. It is important to establish a consistent sleep-wake pattern, seven days a week. Again, this helps to train the body that it will fall asleep at a certain time each evening and awaken and get out of bed at the same time each morning. Getting up and out of bed at the same time each morning is important to avoid disrupting the sleep-wake cycle. This is important even if one had difficulty falling asleep or awakened through the night. One of the most common disrupted sleep-wake patterns for the chronic pain sufferer is to "get sleep when I can." Therefore, if the individual happens to not fall sleep until 2:00 a.m., he or she might compensate by "sleeping in" until noon. Once this pattern gets established, the routine sleep-wake cycle becomes more and more disrupted.
Avoid long naps during the day. Up until recently, it was recommended that a person with sleep problems not take any naps during the day. More recent findings suggest that short naps (e.g. less that 25-30 minute), may actually help energize a person without disrupting nighttime sleep. Long naps during the day (e.g. 1 hour or more) can disrupt restorative nighttime sleep.
Keep a regular schedule. As much as possible, attempt to maintain a routine schedule throughout the day as well as activities prior to bedtime. This might include such things as eating meals at the same time throughout the day, engaging in other distractive or volunteer activities at regular times, and completing the pre-bedtime routine as discussed previously.
Stop caffeine, stop/limit alcohol, and avoid nicotine prior to bed time. In individuals even without a chronic pain problem, research has demonstrated that caffeine use exceeding 250 mg per day increases the likelihood of interference with slow wave/deep sleep. In a person with a chronic pain problem, this situation is likely to be even more significant. Thus, it is recommended that caffeine consumption be eliminated, or at the very least restricted, with the caveat that no caffeine be consumed after noontime. Alcohol has been found to be disruptive to a good night's sleep and should either be avoided or limited in consumption. If a limited amount of alcohol is consumed, it should only be done 4 hours prior to bedtime. Nicotine has also been found to be disruptive to sleep and, again, should be avoided prior to bed time.
Avoid vigorous exercises within four to six hours of bedtime. Regular exercise can promote good sleep, but vigorous exercise just prior to bedtime can be disruptive. Any type of vigorous or cardiovascular exercise should be completed at least six hours prior to bedtime. Relaxing exercises such as yoga can be done prior to bedtime in order to help initiate a restful night's sleep.
Make the bedroom a restful place. The sleep environment should be pleasant and relaxing. The bed should be comfortable, based on choosing the appropriate mattress and pillow, and the room should not be too hot or too cold, as well as not being too bright. Of course, any distracting sounds that might make it difficult to fall asleep or cause awakening during the night should be eliminated.
Practice psychological sleep techniques. Among the most common psychological techniques used to help with a sleep problem are relaxation training, meditation, hypnosis, and cognitive restructuring. These techniques are similar to those used for stress management as well as chronic pain management, and rely on a common set of skills:
These skills, coupled with the deep breathing techniques, can be very beneficial in improving sleep and decreasing the perception of pain by retraining the brain. Many of these skills are coupled with exercise in techniques such as yoga and Tai Chi.
Conclusion
Psychological techniques for improving sleep should be part of any chronic pain treatment program.
Pain diminishes both sleep quantity and quality
The term "insomnia" includes all types of sleeping problems, such as difficulty falling asleep, difficulty staying asleep, and awakening earlier than desired. Of all medical conditions, pain is the number one cause of insomnia. With chronic pain problems, difficulty falling asleep is one of the most prevalent types of sleep disruption. However, awakening during the night and awakening earlier than desired are also frequent problems. Research surveys of those with chronic pain problems have found that 65% report that they are awakened during the night due to pain and 62% report waking too early due to pain. In addition, many patients with chronic pain problems do not feel "refreshed" in the morning when they awaken (a sleeping problem termed "non-restorative sleep").
Pain and sleeping problems need to be treated together
A sleeping disorder associated with chronic pain should always be addressed as part of a multi-disciplinary, chronic pain treatment approach. As with any symptom of a chronic pain syndrome, one should not attempt to treat the sleep disruption in isolation without taking into account proper treatments for the chronic pain problem. Many behavioral and psychological approaches to chronic pain treatment will also help with the symptoms of sleep disorder, and one should not be too quick to rush to medication solutions for insomnia. The use of medications for sleep disruption can be effective but will not be discussed here.
This article focuses on psychological techniques for improving sleep. This assumes that the patient is receiving proper medical treatment for the pain problem and has been thoroughly evaluated for other possible medical problems that might be contributing to the sleep disorder. Some of the common medical problems associated with poor sleep include sleep apnea (a person stops breathing for about 10 seconds or has reduced airflow hundreds of times during the night), restless legs syndrome (a person has an extreme urge to move the legs usually caused by uncomfortable sensations) and other conditions. Once any medical sleep problems have been evaluated and addressed, psychological and behavioral techniques can be implemented.
As chronic pain develops, it is not uncommon for patients to develop bad habits relative to sleep hygiene without even realizing it. An example of poor sleep hygiene habits includes such things as varying the time that one goes to bed and awakens in the morning, taking long naps during the day, engaging in stressful activities such as paying bills while laying in bed, staying in bed most of the day, among other things. Psychological tips to develop good sleep hygiene habits include the following:
Do not go to bed unless sleepy. If an individual does not feel sleepy at bed time, then he/she should engage in some activity that might help to relax. This might include such things as listening to music, reading a book, or practicing some relaxation exercises. It is important to engage in some activity that is relaxing and not stimulating at bed time. Often, watching the evening news can be distracting, but certainly not relaxing.
If one is not asleep after 20 or 30 minutes, then get out of bed. It is important not to lie in bed and "try to fall asleep" for hours and hours. This simply creates a more and more stressful situation making it less likely that an individual will fall asleep. Instead, one should find something to do that will help them feel relaxed and ready to fall asleep. Often, it can be helpful to get out of bed and return to a relaxing activity such as reading a book until they once again feel sleepy. In this manner, patients are training their bodies that a bed is a place to relax towards the goal of falling asleep.
Develop rituals that help with relaxation each night before bed. Often times, it can be helpful to develop "rituals" that one completes just prior to going to bed and getting ready to fall asleep. This might include such things as taking a warm bath, having a light snack, listening to a few minutes of music, or reading. Engaging in the same ritual each evening prior to going to bed can actually train the body that it is time to fall asleep.
Try to go to bed at the same time each night and wake up at the same each morning. Going to the bed at the same time each night helps the body develop a healthy sleep-wake cycle. It is important to establish a consistent sleep-wake pattern, seven days a week. Again, this helps to train the body that it will fall asleep at a certain time each evening and awaken and get out of bed at the same time each morning. Getting up and out of bed at the same time each morning is important to avoid disrupting the sleep-wake cycle. This is important even if one had difficulty falling asleep or awakened through the night. One of the most common disrupted sleep-wake patterns for the chronic pain sufferer is to "get sleep when I can." Therefore, if the individual happens to not fall sleep until 2:00 a.m., he or she might compensate by "sleeping in" until noon. Once this pattern gets established, the routine sleep-wake cycle becomes more and more disrupted.
Avoid long naps during the day. Up until recently, it was recommended that a person with sleep problems not take any naps during the day. More recent findings suggest that short naps (e.g. less that 25-30 minute), may actually help energize a person without disrupting nighttime sleep. Long naps during the day (e.g. 1 hour or more) can disrupt restorative nighttime sleep.
Keep a regular schedule. As much as possible, attempt to maintain a routine schedule throughout the day as well as activities prior to bedtime. This might include such things as eating meals at the same time throughout the day, engaging in other distractive or volunteer activities at regular times, and completing the pre-bedtime routine as discussed previously.
Stop caffeine, stop/limit alcohol, and avoid nicotine prior to bed time. In individuals even without a chronic pain problem, research has demonstrated that caffeine use exceeding 250 mg per day increases the likelihood of interference with slow wave/deep sleep. In a person with a chronic pain problem, this situation is likely to be even more significant. Thus, it is recommended that caffeine consumption be eliminated, or at the very least restricted, with the caveat that no caffeine be consumed after noontime. Alcohol has been found to be disruptive to a good night's sleep and should either be avoided or limited in consumption. If a limited amount of alcohol is consumed, it should only be done 4 hours prior to bedtime. Nicotine has also been found to be disruptive to sleep and, again, should be avoided prior to bed time.
Avoid vigorous exercises within four to six hours of bedtime. Regular exercise can promote good sleep, but vigorous exercise just prior to bedtime can be disruptive. Any type of vigorous or cardiovascular exercise should be completed at least six hours prior to bedtime. Relaxing exercises such as yoga can be done prior to bedtime in order to help initiate a restful night's sleep.
Make the bedroom a restful place. The sleep environment should be pleasant and relaxing. The bed should be comfortable, based on choosing the appropriate mattress and pillow, and the room should not be too hot or too cold, as well as not being too bright. Of course, any distracting sounds that might make it difficult to fall asleep or cause awakening during the night should be eliminated.
Practice psychological sleep techniques. Among the most common psychological techniques used to help with a sleep problem are relaxation training, meditation, hypnosis, and cognitive restructuring. These techniques are similar to those used for stress management as well as chronic pain management, and rely on a common set of skills:
Deep muscle relaxation
Focus elsewhere rather than on the pain
Visual, sound, or other relaxing sensory imagery
Distancing oneself from the chronic pain
These skills, coupled with the deep breathing techniques, can be very beneficial in improving sleep and decreasing the perception of pain by retraining the brain. Many of these skills are coupled with exercise in techniques such as yoga and Tai Chi.
Conclusion
Psychological techniques for improving sleep should be part of any chronic pain treatment program.
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