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5 Articles in this Series
Introduction
Breaking Down Barriers, Including Potential Trauma, When Treating Women in Chronic Pain
Key Goals, Including Healthcare Equity, Emerge from the Chronic Pain in Women Summit
Pain and Sleep: Why It Is So Crucial and How CBT May Help
Sex Differences in Pain Response Matter
Women in Chronic Pain Need More from their HCPs

Pain and Sleep: Why It Is So Crucial and How CBT May Help

With Michael T. Smith, PhD, of the Johns Hopkins Behavioral Sleep Medicine Team

 

Michael T. Smith, PhD, a psychiatrist at the Johns Hopkins University School of Medicine, addressed clinicians and patients regarding the importance of sleep in those living with chronic pain. His talk was part of the July 2019 HealthyWomen Chronic Pain Summit, held in Ellicott City, MD.

Restorative sleep, that is, deep REM sleep, has been linked to a 3-fold pain remission rate, with associations stronger in women with musculoskeletal (MSK) pain, he shared. For chronic widespread pain, or fibromyalgia, restorative sleep has been independently associated with the resolution of pain and a return to MSK health (see the full study by Davies, et al, in Rheumatology). Editor’s Note: In a separate talk at the HealthyWomen Chronic Pain Summit, Mary Driscoll, PhD, spoke about how fatigue is a top complaint among her patients with fibromyalgia.

To achieve this type of restorative sleep, Dr. Smith recommends Cognitive Behavioral Therapy (CBT), which encourages individuals to engage in an active coping process to change any maladaptive thoughts or behaviors that may be exacerbating their pain experience. According to Dr. Smith, CBT can be affordable as it usually only requires four sessions. “Patients respond quickly to the approach,” he said.

If an individual goes to bed or seeks the bedroom to lie down and escape pain, the room begins to be associated with pain as well as feelings of hyperarousal and the inability to sleep (ie, insomnia), he explained. With CBT, patients learn to break this association and to manipulate to-bed and wake times in order to achieve more restorative sleep.

CBT may help patients with pain and insomnia obtain the restorative sleep that they need. (Image: 123RF)

Specifically, a therapist may work with a patient on stimulus control (eg, the bedroom does not equal pain/insomnia) and on sleep restriction. More sleep restriction may seem off-putting to those already sleep-deprived, but by consolidating what Dr. Smith calls “sleep debt,” to achieve more effective sleep in shorter periods. By using a sleep diary to determine how much—and at what times—the individual is actually getting sleep, a therapist can help to create a schedule that rebuilds that person's sleep debt. 

Behavioral therapy such as CBT can have long-term outcomes, said Dr. Smith. “Most patients respond within a month and maintain the approach for 2 years.” Plus, there are minimal side effects, such as the initial sleep deprivation experienced when sleep times are first crunched. What many may not realize, however, is that “CBT is now recognized as first-line treatment for chronic insomnia,” added Dr. Smith, and there are growing links between CBT and pain.

He pointed to a successful 2015 study that he led on individuals with knee osteoarthritis and insomnia, in which low sleep efficiency was associated with increased pain. In the future, he hopes that there may sequenced treatments to help individuals manage dual CBT approaches—such as those for insomnia and those for pain—as this type of therapy requires a lot of behavioral change on the part of the patient.

Next summary: Sex Differences in Pain Response Matter
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