Contributor: Michelle Drerup, PSyD, Sleep Disorders Center
Ah, elusive sleep. Insomnia. Many of us have been there. For people with chronic pain — from arthritis to fibromyalgia to the pain of cancer — sleep issues are especially common. This can include difficulty falling asleep as well as awakening during the middle of the night or waking up earlier in the morning than desired.
Each year, Michelle Drerup, PsyD, of Cleveland Clinic’s Sleep Disorders Center, treats hundreds of patients who come to her with insomnia and a variety of pain-causing medical conditions. “Treating insomnia can actually help a patient’s chronic pain subside,” she says. But before treating a patient for insomnia, she explains, it’s important to rule out other issues that could be causing the problems such as medications or sleep apnea.
Once other issues are ruled out, she says, cognitive behavioral therapy for insomnia (CBT-I) is the treatment of choice.
First: Understanding the insomnia
To understand how chronic pain might make it difficult to fall asleep, it is helpful to think about bedtime routines. Most people when getting ready for bed will eliminate distractions in order to relax and fall asleep including things such as turning off lights, making it quiet and trying to get comfortable.
“This quiet environment can cause problems for people with chronic pain,” says Dr. Drerup, “because then the only thing left for the person to focus on is the experience of his or her 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 the therapy
CBT for insomnia includes a number of strategies designed to improve sleep quality and help people 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 effective for the long-term.
One of the main goals of the therapy interventions is to help patients control or eliminate negative thoughts and worries that keep them awake. Through cognitive restructuring work there is increased awareness of thoughts, and dysfunctional thoughts about sleep tend to decrease which makes it easier to fall asleep.
Another strategy is relaxation training, which is used to reduce or eliminate muscle tension and distract one from racing thoughts. Techniques include progressive muscle relaxation, guided imagery and meditation, among others. Regardless of the type of relaxation strategy used, the treatment involves professional guidance and the teaching of these skills over a number of sessions.
Dr. Drerup conducts individual and group sessions on CBT for insomnia. Usually patients will take part in four to eight sessions to learn these techniques and discover what works for them.
In addition to cognitive restructuring and relaxation techniques, Dr. Drerup goes over the standard guidelines for good “sleep hygiene” as follows:
- Use the bed and bedroom for sleep and sex only. Avoid sleep incompatible behaviors in the bed including reading, watching TV, or worrying.
- Go to bed only when sleepy
- If unable to sleep within 15-20 minutes of getting in bed, get up and go into another room. 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
- Watch caffeine and alcohol intake
- Exercise, but don’t do it too close to bedtime
The good news is that CBT for insomnia has been proven effective with 70 to 80 percent of treated participants.
If you are experiencing insomnia and would like to schedule and appointment with Dr. Drerup, please call 866-588-2264.