Sleep Series – Part 2: Understanding Sleep Problems

Sleep disturbances are one of the most common causes of suffering among people living with chronic pain.  Whilst pain itself directly affects getting and staying asleep, poor sleep feeds into the pain cycle, only exacerbating pain.

In this Sleep Series we will look at: understanding sleep, understanding sleep disturbances and how you can get a better night’s sleep.  Welcome to Part 2: Understanding Sleep Problems.



Part 2: Understanding Sleep Problems

In our last article we discussed what sleep is, why it is important and the impact it has on chronic pain.  In this article we will discuss:

  • What is the relationship between sleep disturbances and pain?
  • What is insufficient sleep syndrome and what are the causes?
  • What is insomnia and what are the causes?
  • What are the treatments for insomnia?
  • What are some other common sleep disorders?
  • What are other factors cause a bad night’s sleep?


What is the relationship between sleep disturbances and pain?

A report released in 2019 by the Sleep foundation found that almost 50% of Australian’s suffer from some type of sleep disturbance.  Research estimates that the prevalence of sleep disturbance in patients living with chronic pain ranges somewhere between 50% and 80%.  Sleep disturbances account for one of the largest sources of suffering among people living with chronic pain.


The relationship between sleep and pain is a bidirectional one, where pain can interfere with getting and staying asleep, and sleep disturbances can exacerbate pain.  Sleep disturbances associated with chronic pain can often be sorted into two categories:

  1. Insufficient sleep: daytime sleepiness, not enough sleep or not feeling rested
  2. Insomnia: trouble falling asleep, trouble staying asleep or waking early



What is insufficient sleep syndrome and what are the causes?

Insufficient sleep is a global issue, relating to a change in our sleep culture based on: our 24/7 lifestyles, longer working hours and extended working shifts.   The increasing prevalence of habitual shorter periods of sleep are associated with an increasing rate of sleep-related issues affecting our mood, weight, work and pain.

The International Classification of Sleep Disorders defines insufficient sleep syndrome as:

“a condition of voluntary, albeit unintentional, sleep deprivation as follows: Insufficient sleep syndrome is a disorder that occurs in an individual who persistently fails to obtain sufficient nocturnal sleep required to support normally alert wakefulness”.

In short, this means you do not get enough sleep at night, resulting in a long term sleep deficit; keeping you from feeling refreshed, alert and well rested (link).  Insufficient sleep syndrome can be the result of choices or actions which prevent you from getting enough sleep; often you are unaware that you require more sleep than you are currently getting.


Causes of insufficient sleep syndrome may include:


The most prevalent issues associated with insufficient sleep syndrome are cognitive impairment (difficulty concentrating, remembering and rationally thinking), obesity, hypertension and insulin resistance (diabetes).

Research shows that insufficient sleep leads to a reduction in your immune function, hormone imbalances and an increase in systemic inflammation. It is also associated with greater levels of burnout, decreased levels of productivity and stress, anxiety and depression.


Interestingly, researchers looked at 21 years of data from the United States and noted that twice a year worldwide, as we adjust our clocks for daylight-savings there has been a correlation between losing an hour sleep and an increase in car accidents.  This retrospective study highlights how a single hour less of sleep can dramatically impact on our concentration.

This is further highlighted in studies looking at driving whilst sleep deprived versus driving whilst under the influence of alcohol.  People who are awake for 18 hours straight, drive like they have a blood alcohol level of .05 (for reference, .08 is considered drunk). Those who have been awake for 24 hours, drive like they have a blood alcohol level of .10.  The lack of sleep results in slower reaction times including braking, swerving away from obstacles and monitoring speeds.


It is important to speak with your doctor to undergo the appropriate testing for diagnosing insufficient sleep syndrome.  They may perform different studies to diagnose insufficient sleep syndrome which include:

  • Sleep studies: to establish if given the chance you would sleep more
  • Physical examination and history: to shows no underlying medical reason
  • Mental health assessment: to show no underlying psychological cause for your tiredness or fatigue.



What is insomnia and what are the causes?

Insomnia is difficulty falling or staying asleep.  People with insomnia can feel dissatisfied with their sleep and usually experience one or more of the following symptoms: fatigue; low energy; difficulty concentrating; mood disturbances; and decreased performance at work or at school.  People with insomnia tend to have difficulty falling asleep (onset), staying asleep (maintenance), and/or waking too early in the morning.  It is important to speak with your doctor to discuss your sleep issues and for a full assessment to be undertaken to diagnose insomnia.


Insomnia can fall under different categories:

  • Acute insomnia is brief (less than 3mths), and often occurs because of life circumstances (for example, when you can’t fall asleep the night before an exam, or after receiving stressful or bad news); many people may have experienced this type of passing sleep disruption, and it tends to resolve without any treatment.
  • Chronic insomnia is disrupted sleep that occurs at least three nights per week and lasts at least three months. Causes of chronic insomnia include changes in the environment, unhealthy sleep habits, shift work, other clinical disorders, and certain medications. People with chronic insomnia may benefit from some form of treatment to help them get back to healthy sleep patterns.
    • Co-morbid insomnia usually occurs as a result or with another condition, such as depression or anxiety; sometimes it’s difficult to understand this cause and effect relationship.
    • Onset insomnia which is associated with challenges getting to sleep at night.
    • Maintenance insomnia which is the inability to stay asleep of a night.


What are the treatments for insomnia?

Due to the complex nature of insomnia, the approach to its management is a multi-modal one, involving a multi-disciplinary team.  Some common treatment’s offered by your healthcare team may involve:

  • CBT for insomnia (CBT-i) is considered the first line response for managing insomnia.  There is alarge volume of research to support its benefits for mild to moderate insomnia, including the long-term benefits that are maintained beyond the course of treatment.  Techniques used for insomnia that have proven to work include stimulus control, sleep restriction, sleep hygiene, cognitive therapy and relaxation therapy.
    • Stimulus control involves only going to bed when you are tired; limiting the activities in bed to sleep and sex; getting out of bed at the same time every morning; and getting out of bed if you haven’t fallen asleep within 20-30mins (learn more here)
    • Sleep restriction aims to restore the natural drive to sleep by restricting time in bed, this is often done under the guidance of a specialist.  It is important to check with your doctor to exclude any health conditions that might be exacerbated by this (learn more about this here)
    • Sleep hygiene involves essentially cleaning up your unhealthy sleeping behaviours, which means avoiding napping during the day; avoiding any stimulants like caffeine and drugs; avoiding eating heavy meals close to bedtime; getting plenty of sunlight prior to bedtime; only using your bed for sleep and sex; ensuring that your bedroom is cool, dark, quiet and comfortable (learn more about this here)
    • Cognitive therapy is aimed at decreasing the anxiety, beliefs and attitudes you have to  sleep and changing the self-talk that often occurs when we aren’t sleeping, such as “I can’t function without sleep”; “I need 8hrs of sleep”; “I never sleep”; “I cannot survive without sleep”; all of which  are destructive to sleep.  The aim is to start looking at sleep as a time of rest and enjoyment not dread (learn more here)
    • Relaxation therapy is anything that acts as a “calmer” on your mind and body and will assist you to sleep, this can include using mindfulness to breaking the train of thoughts; help you to concentrating on right here and now; and stop the judgement of not sleeping and fear of the future tiredness you will experience from not sleeping.  Mindfulness is sometimes all you need to calm your mind enough to fall asleep; but even if you don’t, at least the time you spend awake will be more pleasant and restful (learn more about this here)
  • Medications used for assisting sleep include:
    • Sleeping tablets: they are generally only used for short periods because they can change the quality of the sleep; they also appear to only be effective in managing sleep whilst being taken (to learn more about these visit here)
    • Antidepressants: these can rectify the imbalances in mood and of the neurotransmitters in the brain that assist with sleep (to learn more about these visit here)
  • Bright light exposure (natural or artificial) therapy: is used to harness our natural circadian rhythm and the sleep-wake cycle (learn more here)
  • Diet and lifestyle: changes such as a reduction of smoking, caffeine and alcohol; exercising regularly; spending time in sunlight; and a well-balanced diet such as the Mediterranean Diet (MD), which is high level of tryptophan, all have been shown to have positive influence on sleep and managing stress and anxiety.



What are some other common sleep disorders?

When it comes to sleep disturbances it is important to speak with your doctor to eliminate any other medical reason’s which may be impacting on your ability to get a good night’s sleep.  It is also important to rule out any other common sleep disorders, including:

  • Nocturnal asthma: which is associated with asthma attacks occurring of a night (learn more here)
  • Obstructive Sleep Apnoea: which is associated with breathing interruptions whilst sleeping (learn more here)
  • Parasomnias: which are often associated with sleep terrors, sleep walking, rapid eye movement disorders (learn more here)
  • Sleep paralysis: which is associated with paralysis on waking (learn more here)
  • Restless legs syndrome: which is a neurological movement disorder associated with unpleasant feeling in the legs and a need to move (learn more here)
  • Circadian disorders: which is associated with our internal biological clock being out of synch with the external cues such as sunlight  (learn more here)
  • Narcolepsy: which is a sleep disorder associated with excessive sleepiness (learn more here)


    What are other factors cause a bad nights sleep?

    Researches have noted that many of the routines, activities and habits we have, can be linked to a bad night’s sleep.  Understanding the role these take on our sleep, can help us to change our lifestyles to improve our sleep quality and quantity.
    Some common factors which affect our sleep include:
    • Not having a routine: if you have a consistent bedtime and wake-up time (learn more here)
    • Lack of sunlight during the day: your brain will struggle with organising the sleep-wake cycle due to no external cues (learn more here)
    • Lack of exercise: helps to physically exhaust you, whilst also regulating hormones in your body (learn more here)
    • Pain: affects getting comfortable, getting to sleep and staying asleep (learn more here)
    • What goes into your body: when you drink and eat too close to bed you risk indigestion, late-night bathroom visits and fragmented sleep from alcohol, caffeine, heavy meals, high fat and protein foods (learn more here)
    • Our brain: when our thoughts are racing with anxiety and worry, our brain releases stimulating hormones like adrenaline which prevent sleep (learn more here)
    • The blue light from technology: acts like sunlight switching off melatonin (learn more here)
    • Our environment: if your room is too hot, too light or too noisy you will struggle to get to sleep and stay asleep (learn more here)
    • Watching stimulating tv shows, being on social media or reading stimulating books: can set our minds racing and prevent us from relaxing and getting to sleep (learn more here)


    In our next article we will look at evidence-based tips and tricks for getting a better night’s sleep.  Continue reading Part 3: Getting a better night’s sleep here


    Additional References

    • 2019 Australian Report: Chronic insomnia disorder in Australia (link here)
    • Journal Article:  The association of sleep and pain: An update and a path forward (link here)
    • Journal Article: Extent and Health Consequences of Chronic Sleep Loss and Sleep Disorders (link here)
    • 2019 PARLIAMENT OF THE COMMONWEALTH OF AUSTRALIA: Bedtime Reading.  Inquiry into Sleep Health Awareness in Australia (link here)
    • Journal Article: Sleep and health (link here)
    • Fact Sheets: The Australian Sleep Foundation (link here)
    • Journal Article: Development of a sleep diary for chronic pain patients (link here)
    • Journal Article: Blocking nocturnal blue light for insomnia: A randomized controlled trial (link here)
    • Journal Article: Activity, arousal, and the MSLT in patients with insomnia (link here)
    • Journal Article: Sleep hygiene or compensatory sleep practices: An examination of behaviours affecting sleep in older adults (link here)
    • Journal Article: Stress-induced insomnia: opioid-dopamine interactions (link here)
    • Journal Article: Prevalence of Sleep Disturbance in Patients With Low Back Pain (link here)
    • Journal Article:  Prevalence of Sleep Deprivation in Patients With Chronic Neck and Back Pain: A Retrospective Evaluation of 1016 Patients (link here)
    • Journal Article:  Osteoarthritis and Sleep: The Johnston County Osteoarthritis Project (link here)
    • Journal Article:  Insufficient Sleep—A Population-Based Study in Adults (link here)
    • Journal Article: Cigarette Smoking and Sleep Disturbance (link here)
    • Journal Article: Polysomnographic sleep disturbances in nicotine, caffeine, alcohol, cocaine, opioid, and cannabis use: A focused review (link here)
    • Journal Article: The bidirectional relationship between exercise and sleep: Implications for exercise adherence and sleep improvement (link here)
    • Journal Article: Exploring the Nap Paradox: Are Mid-Day Sleep Bouts a Friend or Foe? (link here)
    • Journal Article: Understanding the Sleep-Wake Cycle: Sleep, Insomnia, and the Orexin System (link here)
    • Journal Article:  The bidirectional relationship between sleep complaints and pain: Analysis of data from a randomized trial (link here)
    • Journal Article: Assessing and Managing Sleep Disturbance in Patients with Chronic Pain (link here)
    • Journal Article: Does work stress predict insomnia? A prospective study (link here)
    • Journal Article: A Systematic Review Assessing Bidirectionality between Sleep Disturbances, Anxiety, and Depression (link here)
    • Journal Article: The role of sleep in the regulation of body weight (link here)
    • Journal Article: Insufficient Sleep Syndrome: Is it time to classify it as a major noncommunicable disease? (link here)
    • Journal Article: Insomnia: prevalence, consequences and effective treatment (link here)
    • Journal Article: Treating chronobiological components of chronic insomnia (link here)
    • Journal Article: Australasian Sleep Association position statement regarding the use of psychological/behavioral treatments in the management of insomnia in adults (link here)
    • Journal Article: Nocturnal Asthma: Mechanisms and Management (link here)
    • Journal Article: Comorbid Insomnia With Obstructive Sleep Apnea: Clinical Characteristics and Risk Factors (link here)
    • Journal Article: Parasomnias (link here)
    • Journal Article: Parasomnias: A Comprehensive Review (link here)
    • Journal Article: Restless Legs Syndrome and Its Relationship With Insomnia Symptoms and Daytime Distress: Epidemiological Survey in Sweden (link here)
    • Journal Article: Severe restless legs syndrome presenting as intractable insomnia (link here)
    • Journal Article: Sleep disorder, Mediterranean Diet and learning performance among nursing students: inSOMNIA, a cross-sectional study (link here)
    • Journal Article: Mediterranean Diet and Changes in Sleep Duration and Indicators of Sleep Quality in Older Adults (link here)
    • Journal Article: Caffeine consumption, insomnia, and sleep duration: Results from a nationally representative sample (link here)
    • Book: How to Sleep Well.  The science of sleeping smarter, living better and being more productive.  Dr Neil Stanley
    • Book: Fast Asleep.  How to get a really good night’s rest.  Dr Michael Mosley
    • Book: Sleep Well Every Night.  A new approach to getting a good night’s sleep. Glenn Harrold
    • Book: The Sleep Coach.  Dr Sarah Jane Arnold
    • Book: This Book Will Make You Sleep.  Dr Jessamy Hibberd and Jo Usmar
    • Journal Article: Sleep and emotions: A focus on insomnia (link here)
    • Journal Article: The effects of sleep deprivation on emotional empathy (link here)
    • Journal Article: The Association of Sleep and Pain: An Update and a Path Forward (link here)
    • Journal Article: Sleep and pain (link here)
    • Journal Article: Sleep and Pain: Interaction of Two Vital Functions (link here)
    • Journal Article: The Effects of Sleep Deprivation on Pain (link here)
    • Journal Article: Duration of sleep contributes to next-day pain report in the general population (link here)
    • Journal Article: Sleep and pain sensitivity in adults (link here)
    • Journal Article: Sleep difficulties, pain and other correlates (link here)
    • Journal Article: Do Sleep Disorders Contribute to Pain Sensitivity? (link here)
    • Journal Article: The role of sleep in pain and fibromyalgia (link here)
    • Journal Article: Negative Mood Mediates the Effect of Poor Sleep on Pain Among Chronic Pain Patients (link here)
    • Journal Article: Intraindividual Variability in Daily Sleep and Pain Ratings Among Chronic Pain Patients: Bidirectional Association and the Role of Negative Mood (link here)
    • Journal Article: Does Effective Management of Sleep Disorders Improve Pain Symptoms? (link here)
    • Journal Article: Total sleep deprivation increases pain sensitivity, impairs conditioned pain modulation and facilitates temporal summation of pain in healthy participants (link here)


    Images courtesy of Unsplash
    Written by Aimee Carter