CBT for Chronic Pain and Insomnia Needs More Research – by Angie Drakulich – April 2018
The Sleep/No Sleep Pain Cycle
Most are familiar with the vicious cycle of insomnia, depression, and increased pain.
Finding the right mix of CBT—including patient education, self-regulation, behavioral activation, and cognitive reframing—may help to break this circle.
Patient education is often the first step.
It’s also important for patients to distinguish between curative CBT for insomnia, which may involve a time-in-bed restriction, relaxation training, and bed re-association, for example, and sleep hygiene, which is preventive and may include steps such as avoiding stimulants, keeping the room dark, and sticking to a schedule.
The Eye-Opening Research
While cognitive behavioral therapy for pain has been well validated and effective in improving patient outcomes (see Williams AC, et al’s 2012 Cochrane Database review and Qaseem A, et al.’s 2016 Ann Int Med review), it has been harder to demonstrate benefit in pain severity, especially when insomnia is involved.
The author says, “CBT for pain has been well validated and effective in improving patient outcomes…”, and then goes on to say, “it has been harder to demonstrate benefit in pain severity, especially when insomnia is involved.”
So which is it?
Four studies examining a variety of pain conditions, combined with insomnia, found that sleep consistently improved with CBT therapy among chronic pain patients.
Pain outcomes did not improve, however, in terms of pain severity scale or pain interference measure
Well, surprise, surprise, pain severity didn’t improve with CBT.
Chronic pain patients have always known that but too many studies were set up in a biased fashion that made it look like it did.
These results were disappointing given the close association between pain and sleep, said Dr. Barwick. Why was there no shift in pain if sleep improved, she asked? Potentially because these studies targeted sleep rather than pain.
Another set of researchers attempted to target pain in patients with a variety of chronic conditions where insomnia was also involved.
The CBT studies showed improved sleep outcomes (less wake time, etc) but, again, on average, no improved pain outcomes.
That’s certainly been the truth for me. No amount or type of psychotherapy helped my pain severity, though it did help me learn to live with it.
But, I have to point out that this was not directly from “therapy”, but from getting support, sympathy, understanding, and encouragement which enabled my own monumental, more-or-less successful, efforts.
Toward a Resolution
So what does all this mean? Clearly, chronic pain, biopsychosocial elements, comorbidities, and individuals make for complex relationships, explained Dr. Barwick.
I don’t understand why they are still doing pain studies on mice if pain is such a complex bio-psycho-social construct. This would seem to indicate that no animal studies of pain can be applied to humans.
- Why does CBT for sleep and pain improve sleep but not pain?
- Is there a unique chronic pain-insomnia phenotype?
- Do altered cognitive and affective regulation, activity level, or autonomic dysregulation severity play a role?
In conclusion, Dr. Barwick said hybrid therapies seem feasible and effective for sleep but not for pain.
An integrated protocol may be the best option for now, especially if it involves refined components and tested protocols in larger populations with longer-term follow-up.
Source: Barwick F. Non-Drug Treatments for Pain and Sleep. Presented at the American Academy of Pain Medicine, April 26-29, 2018. Vancouver, British Columbia.