Opinion & Interviews - Opinion

Cognitive Behavioral Therapy Helps Relieve Insomnia Associated with Chronic Pain

October 2020

Opinion & Interviews - Opinion

Cognitive Behavioral Therapy Helps Relieve Insomnia Associated with Chronic Pain

October 2020

With up to two-thirds of patients with chronic pain conditions also experiencing sleep disorders, two experts from a top US hospital, Cleveland Clinic, suggest cognitive behavioral therapy for insomnia as a potential solution.

For people with chronic pain – whether from back pain, fibromyalgia or the pain of cancer treatment – sleep issues are especially common, and pain is one of the most common causes of insomnia.

“Pain worsens sleep patterns and sleep disturbances worsen pain. It’s a vicious cycle,” says pain specialist Robert Bolash, MD. These problems can range from difficulty falling asleep to difficulty staying asleep, and lack of good sleep can lead to heightened pain and worsening sleep.

His colleague, behavioral sleep medicine specialist Michelle Drerup, PsyD adds that treating insomnia can help chronic pain subside, but before treating insomnia, it is important to rule out other issues that could be causing sleep problems.

“Sometimes, after receiving a new diagnosis, it is common for people to struggle with other disorders that can affect sleep, like depression or post-traumatic stress disorder,” she says.

If people struggle with insomnia, it can also be caused by a sleep-related medical condition, such as sleep apnea. When sleep quality is poor, pain levels are exacerbated. “At times, we see patients with pain diagnoses who really have a medical condition such as sleep apnea. When their sleep apnea is treated, their pain diminishes as well,” Dr. Bolash explains.

The two experts recommend the following three-pronged approach that could help people to address their insomnia.

First: Understanding the insomnia

“To understand how chronic pain might make it difficult to fall asleep, it is helpful to think about your bedtime routine,” says Dr. Drerup. Most people will eliminate distractions in order to relax and fall asleep, including measures such as turning off lights, making it quiet and getting comfortable.

“But this quiet environment can actually cause problems if you have chronic pain,” says Dr. Drerup, “because then the only thing you have to focus on is your pain.” Unfortunately, without other distractions, pain seems to become “louder” and in many cases, the perception of pain — not necessarily the actual pain — increases when attempting to fall asleep.

Second: Understanding good sleep habits

For these strategies to work, the experts say, you also need to follow good sleep hygiene. These are necessary, but not sufficient strategies -– basic building blocks that should be implemented in order to improved sleep patterns. Here, Dr. Drerup offers highlights of the standard guidelines:

  • Avoid sleep-incompatible behaviors in bed, including reading, watching TV or worrying.
  • Go to bed only when sleepy.
  • If unable to sleep within approximately 20-30 minutes of getting in bed, get up and go into another room and do something boring, quiet and relaxing.  Return to bed only when sleepy again. (Repeat if necessary.)
  • Maintain a regular wake time regardless of the amount of sleep that night.
  • Avoid naps during the day.
  • Avoid caffeine and alcohol before bedtime.
  • Exercise, but not within a couple hours of bedtime.

Third: Understanding the therapy

Cognitive behavioral therapy for insomnia (CBT-I) includes a number of strategies designed to improve sleep quality and help change thoughts and behaviors that interfere with sleep. This type of therapy is often preferred over medications because it has no side effects and is a more effective long-term solution.

One of the main goals of CBT-I is to help people control or eliminate negative thoughts and worries that keep them awake. CBT-I helps people to become more aware of thoughts related to sleep. “Once controlled, those thoughts tend to decrease and it is easier for you to fall asleep,” says Dr. Drerup.

Another strategy to help with insomnia is relaxation training, which reduces or eliminates muscle tension and distracts from racing thoughts. Techniques include specific muscle group relaxation, guided imagery and meditation.

“Regardless of the type of relaxation strategy used, the treatment involves professional guidance and teaching these skills over a number of sessions,” Dr. Drerup says. She conducts both individual and group sessions on CBT for insomnia. “Usually, patients will take part in three to eight sessions to learn these techniques and discover what works for them,” she says.

The good news is that CBT for insomnia has been proven effective with 70 to 80% of patients who seek this treatment, says Dr. Drerup.