Sleep Quality, Depression, Pain and Disability

Felix Naughton and his colleagues conducted a study to examine the relationship between sleep quality, depression, pain severity, and disability. Their results (reported in the journal Pain) showed that sleep quality did not directly affect disability, but rather that poor sleep quality tended to make people feel more depressed and tended to make their pain feel worse. These changes, in turn, increased disability. In a study involving people with fibromyalgia, Nancy Hamilton and her colleagues reported a complex set of  findings in which poor sleep had a cumulative effect on negative emotions and interfered with emotional recovery on days in which the person experienced a high number of stressful, negative events.

The results of such studies provide scientific verification for what you may know from your own experience: sleep plays a crucial role in the daily experience of people with chronic pain.

There are a number of sleep problems,  including sleep apnea, narcolepsy, restless legs syndrome, and insomnia. All should be evaluated by a physician. I want to talk about insomnia, the most common sleep disturbance. There are several varieties of insomnia:

•  trouble falling asleep
•  trouble staying asleep
•  waking up very early and being unable to get back to sleep
•  a combination of two or all of the above

Of course, you may say you can’t fall asleep because you are in pain and then, your lack of sleep makes you hurt more, you may feel your mood worsening, you may feel able to do less, feel bad about that, then sleep less…and the cycle continues. Although this is a frustrating series of events, the nice thing about cycles is that you can interrupt them in one part of the sequence and have effects in other parts of the cycle. Let’s think about how you can interrupt your insomnia cycle. Take a look at the figure below. It shows five factors that impact sleep quality.

Let’s start with pain severity. Start by exploring what factors may reduce your pain. Do some experiments with what helps so you can create a list of pain soothers. A pain soother is anything that you can do that reduces your pain somewhat. The key here is to realize that although it would be great to be pain free, pain reduction is good too and will help you to feel more comfortable. If you are a subscribed member of the Chronic Pain Management Program, you can use our Pain Soothers program to help you figure out what helps. If you are not a member, try some things such as heat, cold, stretching, a hot bath, a soak in a hot tub…Write down how much pain reduction you get from each to determine what helps most. Make your pain soothers part of your life by scheduling them on your calendar.

Your sleep environment should be a room that is comfortable, clean, not too cluttered, neither too hot nor too cold.  It should be a haven. Do not work in bed or in your bedroom. Watch TV or use your computer in another room. Use your bed only for sleep and sex. Take 5 minutes each day for the next week: evaluate your bedroom and make changes to make it a room that is relaxing and comfortable. This need not cost any money.

Experts on sleep often make a similar set of recommendations regarding sleep habits. One of the most important: go to bed and get up at the same time each day – yes, that means weekends and vacations too. This helps to maintain a regular sleep cycle in your brain. No caffeine after about 2 PM. If you haven’t been able to quit smoking, start working on not smoking at night. Know this when you light up: your smoking keeps you up!  Exercise is great, but don’t do it at night. Don’t lie in bed tossing and turning. If you haven’t fallen asleep after 20-30 minutes, get up and do something for a short time, then try again. Don’t use alcohol to help you sleep. It may help a bit at first, but it will lead to disrupted, non-refreshing sleep…and over time you will need more and more to get to sleep.

Anxiety and physical arousal are covered somewhat by the list above regarding stimulants. If you still feel anxious even without caffeine or other stimulants, consider trying relaxation or meditation. Make it a regular part of your routine. It doesn’t have to be 30 minute session. Start with 5-10 minutes!

People with insomnia often get caught up in thoughts that make their insomnia worse. Do you lay in bed worrying about how you will go to work after only a few hours of sleep? As bedtime approaches, do you start worrying about whether you will be able to sleep? When you are unable to sleep, do you watch the clock and think about how little sleep you are getting? These are all perfectly natural responses – but they only make you more anxious and your insomnia worse. Take control of your thoughts so that you are not making yourself feel more anxious than you need to. It would be very helpful to track your thoughts for a day or two, looking for thoughts that, although they may feel natural, only make you anxious. You can learn to think about your insomnia in a way that is realistic, hopeful, reassuring, and problem-focused. Using our monitoring form, ask yourself the following questions:

•  What is the evidence this thought is true?
•  What is the evidence this thought is NOT true?
•  Does believing this thought offer hope or promise for the future?
•  What are some other ways I can look at my situation? What are some more realistic, hopeful, and reassuring replacement thoughts?
•  What positive, constructive action can I take?
•  What sincere, helpful advice would I give to a friend who was having the same anxious thoughts?