Tammy Applegate dreams of sleep – when she dreams, that is. Most nights, she can’t sleep soundly; pain rousts her four or five times. She turns over, repositions the pillow under one shoulder – the only position that offers some relief – and waits for slumber to overpower her discomfort. “Sometimes it takes me so long to get comfortable that I stay awake anywhere from 30 minutes to a couple of hours,” says the Fort Worth, Tex., mother of four, who has mixed connective tissue disease and requires sleep treatments to resolve her issues with pain and sleep.
She’s got plenty of company. Insomnia – broadly defined as having trouble falling or staying sleep – affects anywhere from 10 to 40 percent of American adults, at least intermittently, according to population studies. It’s estimated that some 10 to 15 percent have long-term sleep problems (lasting more than a month).
If you have problems with pain and sleep that seem intractable, don’t lose hope. There are ways to improve your chances of getting a good night’s rest.
What Goes Wrong
Adults usually need between seven and nine hours of sleep a night. Ideally, that sleep comes in cycles, played out in roughly 90-minute segments throughout the course of a night. It includes rapid eye movement (REM) sleep, in which you dream, and four stages of non-REM sleep. First you enter several stages of non-REM sleep, descending from stages 1 and 2 into stages 3 and 4 – the deeper and more restorative stages. You then resurface and enter REM sleep. Then another 90-minute cycle starts.
Insomnia – the disruption of the sleep cycle – comes in two forms. Secondary insomnia is a side effect of another condition, illness or behavior. In addition to arthritis or fibromyalgia, for example, it can be caused by poor sleep hygiene; stress; and a range of medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids and, for some people, statins (such as Lipitor and Zocor).
With primary insomnia, however, there is no clear cause as to why people can’t sleep. It may be triggered by a major stressful event or by disruptions in your sleep routine (caused by travel or work). Researchers are also examining whether some people simply are predisposed to insomnia.
Even normal aging takes a toll: As we grow older, we naturally get less restorative sleep and are more likely to wake up in the night – although the amount of sleep we need doesn’t change.
Just worrying about insomnia can make it worse, so that it becomes a self-fulfilling prophecy, says Art Spielman, PhD, a longtime sleep researcher and psychology professor at The City College of The City University of New York. “If you think you are not going to fall asleep, you don’t fall asleep,” he says.
The Sleep/Pain Cycle
Achieving restful sleep can be particularly difficult for people like Applegate who have chronic pain. “Pain is a lump of coal under your mattress,” says Spielman. “Even when you’re asleep, the mind can register pain.”
People may notice obvious signs of pain and sleep problems, such as not being able to fall asleep or waking up frequently due to discomfort, says Michael Smith, PhD, director of the sleep psychophysiology laboratory at Johns Hopkins University in Baltimore. Or – and Smith believes this may be more disabling – they have disruptions in the sleep cycle itself so that they sleep but don’t get enough deep sleep. They may be aroused during sleep and pushed from deep sleep into a lighter stage without ever knowing it. “Their deeper sleep is disrupted by arousals or outright awakenings,” Smith says. “They may sleep 10 hours but feel groggy and unrefreshed the next day.”
That also may be the case for people with fibromyalgia, who tend to have abnormalities in deeper-stage sleep. Researchers have explored whether sleep disorders cause the pain of fibromyalgia or vice versa, but it’s still not clear.