Sleep (Living Beyond Pain Podcast)

Sleep (Living Beyond Pain Podcast)


[Narrator] Stay tuned for [Army] Army Capt. Tracy Beegen,
of the “Living Beyond Pain” podcast, produced by the Defense Health Agency. [music] [Army Capt. Beegen] Welcome to the
“Living Beyond Pain” podcast. Today’s episode is going to focus on sleep
and the impact that it has on how we experience our pain. Joining us today is Dr. John Peachey who is
a health psychologist working at the Naval Medical Center in San Diego. Welcome to the show Dr. Peachey. [Dr. John Peachey] Thank you for having me. I’m happy to be here. [Beegen] So sleep and chronic pain really
go hand-in-hand. And I’d like you to explain to our listeners
the impact that sleep can have on chronic pain. [Peachey] Certainly. What we call a bi-directional relationship,
which is a fancy way of saying that pain messes with your sleep and sleep can mess with your
pain. More complicated than that, there’s a number
of things that explain the relationship between these two. First, when people are sleep deprived, that
is when people get less sleep than they should, they typically report higher levels of pain. And you can actually do an experiment where
you keep people awake and they will report more pain the next day in support of that. There’s also this connection between pain
and inflammation, and specifically there’s certain foods which increase inflammation
in our body. And by the way, when we don’t get enough sleep,
we crave more of those kind of foods, those junk foods. So in a roundabout way that can cause our
pain to increase. Additionally, we gain more weight when we’re
not getting good quality sleep, and the more weight we have to carry around, typically
the worse our pain gets. And it also goes the other direction too though. If I have problems with pain, I’m more likely
to have disruptions in my sleep. If I have problems of pain, I’m more likely
to be less active overall because of the pain, but the less active I am, the worse my sleep
is going to be. So I could go on and on and on about this
bi-directional relationship between the two, but basically if you have problems with sleep,
you’ll be at risk for more pain problems, and if you have pain problems, you’re probably
going to have sleep problems. So in other words, if we want people to get
better, we got to fix them both at the same time. [Beegen] So the relationship between sleep
and pain really sounds like a vicious cycle. In your work with veterans, what’s been your
experience of their view of sleep and their need for sleep? [Peachey] It’s funny because I’ve been on
both sides of this. I mean, I’ve worked for the last five years
or so with active duty and then prior to that I was working with veterans. And when I was in the V.A. hospital, I worked
with a lot of people who had sleep difficulties, and the common theme there was that they had
felt that the military had done an excellent job teaching them how to survive on little
to no sleep, but they never really untrained that. That is to say that did them a lot of good
in some ways. It was adaptive and helpful for them to learn
how to survive on little to no sleep because in a combat situation you don’t really have
any control over that. But once people get out of the military, as
if there’s anyone listening might know, they don’t want to stick around necessarily and
go through some treatment for sleep problems. They just want to go home. So at any rate, there’s just a pattern, I
think, generally within the military population, of people who have sort of learned to sleep
with one eye open as I like to call it, because that was helpful for them. But now that they’re in the civilian world,
that’s not so necessary but it’s hard to unlearn, because if your brain thinks, “I got to keep
one eye open to stay safe.” it’s not going to want to give that up. A common problem but relatively doable to
get rid of it. [Beegen] That’s something I also see in my
patients. There’s almost this sense of pride of, “I
can function on three hours of sleep.” or, “I only need four hours of sleep and I’ll
be fine.” But long term that’s not really healthy to
maintain. So can you tell our listeners what would be
some good strategies or interventions that they could implement to kind of interrupt
that cycle or even just shift it a little bit? [Peachey] Well, I think one of the key concepts
of chronic pain management is that we need to move a little bit every day, and so typically,
when people increase their physical activity, not only can that in the long run help with
pain but that also typically increases the quality of our sleep or the depth of our sleep. So being physically active even if that just
means walking around the block, it goes a long way to helping both of these things pretty
directly. [Beegen] So movement actually increases our
ability to sleep, is that what you’re saying? [Peachey] Well yes, but more precisely, when
we do physical activity or exercise, our body gets these little tiny tears in our muscles,
which they have to repair themselves at night, and our body repairs itself with growth hormone. And so in other words, if we get some physical
activity our body fills this strong desire to get into deep sleep, which is where this
growth hormone is created and released in our body, which is all a fancy way of saying
the more physically active we are the more sleep we need because our body needs to repair
itself. [Beegen] So Dr. Peachy, if we just google
sleep, some of the first things that pop up are circadian rhythm and sleep drive. Can you help break those concepts down for
our listeners? [Peachey] Sure. So I think there’s two main systems in your
body which control your sleep, and you can kind of think of them as like yin and yang
a bit. And one of these systems we can call it the
sleep drive and one of these systems we would call the wake drive. So the sleep drive is the thing that makes
us feel sleepy and simply put, the longer we’re awake the sleepier we feel. And then when we go to sleep at night, our
body cleans out this sleepy chemical from our brain and helps us feel better the next
day. The other system, the wake drive, sometimes
that’s called the circadian rhythm but it’s basically this internal clock that tells us
when it’s time to be awake. Most of us want to be awake when the sun’s
up, although some people are true night owls or morning larks. So when you’re thinking about a sleep problem
someone may be having, you have to think about both, “Are they sleeping at the right time
for their body?” But you also have to think about, “Do they
have enough drive to sleep?” Like someone who’s napping all day long is
probably going to have a hard time sleeping at night because there’s not going to be much
of a drive to go to sleep. [Beegen] And that’s something that my patients
tell me quite frequently is when they have a pain flare-up, they really feel very fatigued
and feel like they need to rest and they’re equating resting with sleeping or napping
during the day, and that really takes away from that sleep drive. [Peachey] Yeah. You’re touching on a really important point
actually for me. And that is that there’s an important distinction
between sleepiness and tiredness. So sleepiness is like, “I can hardly keep
my eyes open. If I had a decent bed I’d probably go to sleep
pretty quickly.” Tiredness means something different medically. And what I mean by that is physical fatigue
or mental fatigue. So if I worked out really hard at the gym,
when I’m done I’m probably going to feel tired but not necessarily sleepy, or if I took a
really hard test, again, I might be sort of mentally wiped out, but again not ready for
bed. So a lot of folks struggle with this or misunderstand
this and they think, “Well, I’m tired so therefore I should go take a nap.” And that’s actually not at all what they need
and it potentially could be causing problems later that night. So I think that’s kind of an important distinction
for folks to make. [Beegen] I also wanted to ask your opinion
and if you could share with our listeners what are some other factors that could impact
sleep and the quality of sleep, especially for those folks that are experiencing chronic
pain? [Peachey] I like to say that sleep is a barometer
for our overall health, which means if we’re having medical problems in any area, we’re
probably going to have some sleep problems. Our sleep is impacted by a lot of factors,
movement as we’ve talked about, our medical health as well. There’s also some social and cultural factors
related to our sleep. For example, whether people share beds with
their other family members. One of the things with regard to chronic pain
specifically is that it’s really common for folks to start to feel isolated from other
people and as a result they end up staying up later because it doesn’t really matter
if– especially if they’re not working because of the pain condition in part. So the kind of easy-out answer is basically
everything can be a factor that influences our sleep. But a big one separate from those two systems
I was talking about earlier is also our stress system. So if I’m worrying about something or just
even thinking about what I need to do tomorrow, that will overpower my sleep drive potentially
and my wake drive. So the list truly goes on and on. [Beegen] Well, and something that I often
hear is, “I have insomnia and I lay awake at night and I worry.” or, “I can’t fall asleep.” or, “I fall asleep and then I wake up a half
hour later, an hour later. So I must have insomnia.” Are there some other medical conditions that
could be going on with someone other than insomnia? [Peachey] Certainly. One of the more common sleep conditions separate
from insomnia is sleep apnea or obstructive sleep apnea, which coincidentally is more
common in veteran and military populations. So what that is, is some people are snoring
at night and then they end up essentially holding their breath. It’s not intentional but they’re trying to
breathe and their airway has just closed down on itself so that no air is getting through. So if you hear your bed partner for example
snoring and snoring and holding their breath at night, there’s a good chance that this
may be happening and certainly you would want to talk to your doctor about that in more
detail. Separate from sleep apnea, another common
interfering sleep problem is some folks have nightmares, which interfere with quality of
their sleep. There’s more benign things like sleepwalking,
which are common, but they’re not really a problem that we worry about much in the clinical
area. I think the last one I would mention is that
some people– we were talking earlier about the internal clock in our body, the circadian
rhythm, some people are just naturally they don’t want to sleep during the night. Their bodies want to sleep during the daytime
or at times that are not sort of culturally normal. This is a really common thing I actually see
pretty frequently and often can contribute to insomnia sort of separately. [Beegen] If our listeners are experiencing
some of these things and maybe their sleep partners are saying, “Hey, you’re snoring. You’re holding your breath.” We really want to encourage them to go and
see their primary care doctor and see if a referral to a sleep clinic would be appropriate,
and making sure that they’re really being treated for those other conditions that could
be contributing to sleep difficulties. [Peachey] Certainly. [Beegen] Now, what are some helpful tips for
our listeners to improve their quality of sleep? [Peachey] Lots of ideas come to mind but first
of all, a normal healthy perfect sleeper is going to naturally wake up every 90 minutes
roughly all night long, so we all do this. That is to say waking up at night isn’t really
a problem but remembering that you wake up at night and staying awake for a period of
time is, because perfect healthy sleepers would wake up and roll over and just go right
back to sleep. So what you’re doing during that period of
time is kind of critical, and what a lot of people do which is not a very good idea is
they check the time in the middle the night. The problem with that is a couple of things. Firstly, it’s impossible to avoid doing math
when you look at the clock. You’re going to go, “How long has it been
and how long do I have left?” And math wakes up the brain certainly. And then if it’s bad news, that wakes up the
brain more. So one recommendation is set your alarm clock
and put it out of reach. If it’s your phone or if it’s a bedside alarm
just push it away. And then if you wake up at night it doesn’t
matter what time it is and that’s what you say to yourself. You say this, “Brain, it doesn’t matter. The alarm will tell me when it’s time to wake
up.” And what you find if you can stop checking
the time usually after about a week or so is people stop realizing that they’re waking
up at night because they’re not as a result, getting alerted by looking at the time. The other thing I would recommend kind of
more towards the beginning of the night is many people have this problem where it’s difficult
to turn off their mind. Their mind is racing at night when they get
in bed. And it might be about real legitimate problems
or it might be about, “What am I going to do for lunch tomorrow?” But nonetheless, it’s just really hard to
turn off the mind in bed. A lot of people have this problem. And one of the techniques that works really
well is to sort of make a deal with yourself. You go, “OK brain, look, I don’t want to be
thinking about these things all day long. I certainly don’t want to be thinking about
these things in bed at night. So since I can’t make you just stop, I’ll
make you a deal. We will worry or think about these concerns
earlier in the evening maybe at 5 p.m. and I will actually schedule into my day, 15 minutes
to sit and think about whatever these concerns might be.” As silly as that sounds, what happens if you
follow through on that for a few days is your brain actually starts to believe you and it
starts to quiet down when you get in bed and quiet down in the day, kind of knowing that
it’ll have its time to air the dirty laundry and think about all these problems and so
forth. I wouldn’t do this right before bed but otherwise
you can pretty much do it whenever you want and it’s just one of those things that I’ve
had endless people telling me has helped them to quiet their minds at night. [Beegen] Well, and that brings up a really
good point about not doing it right before bed or even in bed, because we really want
to associate bed with sleeping. And if we’re laying in bed and we’re awake
and we’re worrying, that’s what we’re going to associate with when we go to bed, and we
really want to retrain our brains to think about and to associate our bed with sleeping. [Peachey] Definitely. And likewise, just to kind of add on to that,
you don’t want to jump in bed and then relax and unwind in bed while you’re waiting to
get sleep. You want to stay out of bed and relax and
unwind and only get in when you think it’s coming soon. So that’s why it’s really critical to have
at least 30 minutes before you get in bed of just turning off the screens, putting the
lights down low, and doing something relaxing, whatever that is for you, whether it’s playing
guitar or knitting or meditating, doesn’t matter. As long as people do that, usually they’ll
become more aware of how sleepy they actually are. [Beegen] And I’ve got to say, that’s one thing
that I am guilty of. Sometimes, I’ll just pop into bed and I’m
scrolling through social media or playing a mind-numbing game just to shut my mind off
and, like you said, putting that phone away and not even having it near your bed can really
be helpful in breaking that habit. I also wanted to ask you, because a number
of my patients talk about they can’t really sleep in their bed and so they they sleep
in a chair or on the couch. Is that something that is recommended or what
would you say to our audience members that really have a difficult time finding a comfortable
position so they can’t sleep in their bed? [Peachey] That touches on a couple of subjects. So the first thing that you’re touching on
is what we call conditioned arousal. Basically how I like to think about it is
that ideally our brains think bed equals sleep, but if we have poor sleep or we don’t sleep
in bed over many weeks or months or years, over time our brain will come to learn bed
equals wakefulness or stress or something else. And so what a lot of people tell me is that
they’ll be sitting on the couch just relaxing before bed and starting to do that head-nod
thing and they go, “OK. It’s time for me to go to sleep.” and they get in bed and suddenly they’re wide-awake. And that’s because their brain’s saying, “Oh,
here we go again. Time to see how long it takes to sleep tonight.” So if we want to prevent that from happening
or if we want to fix that if it’s already happening, we do have some general guidelines
where we say, number one, don’t get in bed until you’re about to fall asleep. Number two, don’t stay in bed if you’re not
sleeping because you’re just making it worse, and three, just use your bed for sleep. You don’t want to hang out there and watch
TV there or talk about finances or whatever it might be. And that kind of gets at the other point that
you’re touching on which is with chronic pain specifically. When folks are especially in a pain flare-up
and in a state where they’re just trying to take it easy as much as possible and relax
and not move too much, typically they end up sitting on a recliner, sitting on the couch,
and then as the hours go by, it might suddenly become night and then, “What the heck? I’ll fall asleep here. I’m already comfortable.” But from what we were just talking about a
moment ago, it’s really not a good idea to have your mind thinking you have multiple
sleeping places. So I kind of think when people say, “I really
truly for pain reasons cannot sleep anywhere but, say, in my recliner.” I’m flexible. I would say to that, “That’s OK. As long as you don’t sit in that recliner
all day long and watch TV and do other things there. If all you do is sleep in that recliner and
you don’t sleep anywhere else, whatever works.” [Beegen] Yeah. I even would encourage my patients to, “OK. If that’s your recliner, bring it in your
bedroom if that’s possible, so that you’re associating that recliner and that space with
sleeping.” Just like you said, we’re retraining our brain. We’re trying to teach our brain that this
is the place we sleep, this is the space we sleep in, and these are the times we’re going
to bed. Having that routine so that our body starts
to adjust to it. And just like you had said a moment ago, it
takes time, and I know a number of my patients get frustrated at first because they say,
“Well, I’m trying this but it didn’t work this week.” And so we really just want to encourage our
listeners to take that time to be consistent and let it happen over time. Now, I’m not saying if you’re doing everything
that your primary care provider or your behavioral health provider’s requesting of you as far
as those sleep regimens and sleep restriction schedules, if you’re doing a cognitive behavior
intervention for insomnia, we really want to make sure that something else is going
on. We want to address that. But for those patients, give it that time. Give it a chance to work. It’s not just going to happen overnight. [Peachey] No pun intended [laughter]. [Beegen] For our listeners that are experiencing
insomnia, is there any treatment that they can seek out that is helpful in treating insomnia? [Peachey] There’s several treatment options
but the treatment of choice is Cognitive Behavioral Therapy for Insomnia or CBTI. And actually, I think about two or three years
ago there was major physician organization in the United States which said, “This should
be our first line intervention moving forward. We should not be trying medications first
but we should be trying cognitive behavioral therapy, and then and only then if it fails
should we then reconsider something like a medicine.” Strongly supported, lots of research. And essentially, how I think about it is a
lot of people, a lot of your listeners have probably heard of or may have heard of sleep
hygiene, and when they hear about, “Oh, someone’s going to help you sleep better.” They go, “You know what? I’ve already heard about the sleep hygiene
thing and it doesn’t work for me.” Getting to the point you were saying a moment
ago, it’s good to think about these things as like it’s about finding the right recipe,
and just because you tried these ingredients in the past and it didn’t turn out right for
you doesn’t mean they’re all bad ingredients. It just maybe wasn’t the right recipe for
you. So with regard to sleep specifically, kind
of behavioral therapy for insomnia is looking at changing our behaviors and also changing
our thinking about our sleep and the sleep environment and how much sleep we need and
so on and so forth in order to help people sleep better. And so a lot of this is education. Sleep hygiene does make up a portion of it
but it’s important for people to understand that sleep hygiene on its own isn’t going
to treat an insomnia problem. It’s more preventative, kind of like flossing
your teeth in dental hygiene. It’s not going to fix a cavity but might prevent
you from getting one in the first place. So what I’d like to do is give a lot of education
about how your sleep systems work so that it becomes kind of more obvious about what
messes it up and what they should avoid doing. And then finally, what we do is, as we were
talking about earlier, we work hard to help retrain people’s brains so that when you get
in bed your brain says, “It’s time for me to go to sleep.” [Beegen] And that’s something that I really
find with my active duty patients and the veterans that I’ve worked with. They understand training and they’ve been
able to be successful in learning new skills. So if we can frame it that way to say, “I’ve
been successful in the past in learning these new skills, so maybe I don’t have them right
now but I can learn them.” And so really encouraging them that they’ve
been successful learning new skills in the past and this is just a new skill set that
they’re going to be learning and really talking about the benefits of if they can learn these
and be successful, what that would mean for them in the long term. Because when we talk about our sleep, it really
does impact. Like you said, it’s that vicious cycle. It impacts our emotions. It impacts the way we function. It impacts our mental focus and mental clarity. Oftentimes, I know when I don’t get a good
night’s sleep I am not very sharp the next morning and I’m usually pretty grumpy. So I know just with that factor, and then
if you add in you’re experiencing a pain flare-up and you don’t have sleep, that really does
impact how we function and how other people relate to us. So again, that cycle of feeling isolated,
socially isolated because people don’t want to be around us if we’re grumpy. And frankly, I don’t like being around people
when I’m in pain. I’ve had some different conditions where I’ve
had to recover and people would treat me like I’m going to break or that I needed to keep
it easy. And so I found that that vicious cycle again
of that pain and that sleep really just feed into each other. So using those behaviors and those strategies
and seeking out that CBTI, the cognitive behavior therapy for insomnia, if insomnia is what’s
going on, can really be helpful in breaking that. [Peachey] When we work on your sleep and we
work on your pain simultaneously, that’s going to give you the best chance for success. If we ignore one of those while working on
the other one, the other one we’re ignoring is probably going to keep the problem going
and it won’t really get much better. [Beegen] Well Dr. Peachey, I just really appreciate
the time that you’ve taken with us today to discuss the impact of sleep on our pain. For our listeners, there’s some great resources
below in our show notes. There’s some great apps. The “CBTI Coach” can really be helpful
in tracking your sleep. And so like we talked about, being intentional
about observing what our sleep patterns and how they’re impacting us. And there’s some additional resources that
can be helpful in tracking our moods and seeing what the relationship is between our moods
and how we sleep can be helpful. So again Dr. Peachey, is there anything you’d
like to leave our listeners with? [Peachey] If you let your body sleep when
it wants to, it will sleep about eight hours a day, which in other words is about a third
of our lives. If that doesn’t convince you that your sleep
is important, I don’t know what will. Sweet dreams. [Beegen] Well, thank you again for joining
us. For our listeners, please join us again for
our next episode of “Living Beyond Pain” where we provide you with practical tools
to help you limit and reduce the intensity, the frequency, and the duration of your pain
flare-ups. [Beegen] The “Living Beyond Pain Podcast”
is produced by the Defense Health Agency. Until next time, be well. [music]
[Beegen] Join us on “A Better Night’s Sleep”, the podcast that provides sleep tips, information
on sleep disorders, and evidence-based treatment. We’ll talk with leading experts in sleep and
sleep disorders. Although we made this for the military community
everyone can use a better night’s sleep. [music]

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