Living with Pain? Here’s Why Sleep is So Important and How CBT Can Help

Cognitive behavioral therapy can help individuals restore crucial sleep debt in individuals experiencing both restless nights and chronic pain.

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, shared Michael T. Smith, PhD, a psychiatrist at the Johns Hopkins University School of Medicine, and part of the university’s Behavioral Sleep Medicine team. For chronic widespread pain, or fibromyalgia, in fact, restorative sleep has been associated with the resolution of pain and a return to MSK health, he added. Dr. Smith was speaking to an audience of both pain patient advocates and clinicians at the July 2019 HealthyWomen Chronic Pain Summit, held in Ellicott City, MD.

To achieve this type of restorative sleep, Dr. Smith recommends Cognitive Behavioral Therapy (CBT). A type of short-term psychotherapy, CBT provides a present-focused approach that 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. (Read more about how CBT helped individuals living with other chronic pain conditions.)

Cognitive behavioral therapy may help restore crucial restorative sleep in those experiencing both restless nights and chronic pain. (Image: 123RF)

If you go to bed or seek 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 (eg, insomnia), he explained. With CBT, you will learn to break this association and to manipulate your to-bed and wake times in order to achieve more restorative sleep.

Specifically, a therapist may work with you 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,” you can achieve more effective sleep in shorter periods. By using a sleep diary to determine how much—and at what times—you are actually getting sleep, a therapist will work with you to create a schedule that rebuilds your sleep debt. To explain, if you are only getting 3 hours of good sleep each night, say between 2 am and 5 am, the therapist may ask you to stay awake until 2 am rather than tossing and turning in bed for several hours prior. By 2 am, your mind and body will be ready to sleep more efficiently within a shorter window of time. This will require forming a new sleep pattern at the beginning, but then the to-bed time may be rolled back by 15 minutes each week or so, and eventually, you may be able to fall asleep—and stay asleep—at 11 pm.

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 patients living with pain 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. Read about how CBT and ACT (Acceptance and Commitment Therapy) work.

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.

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. PPMcovered her talk as part of its professional/clinical coverage


More on the chronic pain and insomnia cycle and how fatigue makes its way into chronic conditions.

Updated on: 08/29/19
Continue Reading:
CBT and ACT Therapy for Chronic Pain: How Does Psychotherapy Help?