Shorter communicationHybrid cognitive-behaviour therapy for individuals with insomnia and chronic pain: A pilot randomised controlled trial
Highlights
► We tested a new treatment that targets both insomnia and pain-related interference. ► The hybrid treatment involved 4 weekly cognitive-behaviour therapy sessions. ► Compared to symptom monitoring, the hybrid treatment was linked to greater improvements in sleep. ► The treatment was also linked to greater reductions in pain interference, fatigue and depression. ► All treatment-associated gains were maintained at 1- and 6-month post-treatment.
Introduction
Chronic pain affects tens of millions of people worldwide (Gureje et al., 1998). Aside from the unpleasant sensation and potential restrictions on functioning, people with chronic pain are at higher risk of developing anxiety, mood, substance misuse and/or physical health problems (Von Korff et al., 2005). One debilitating comorbidity of chronic pain is insomnia. More than half of patients seeking treatment from pain clinics have insomnia that warrants clinical attention (Tang, Wright, et al., 2007). Compared with pain patients without problems sleeping, those with insomnia report greater pain, fatigue and disability (Nicassio et al., 2002).
Several findings on the interaction of sleep and pain are of clinical relevance. First, many cases of insomnia persist despite continuous use of hypnotics (e.g., King & Strain, 1990) and ongoing treatment for pain (e.g., Gustavsson & von Koch, 2006). Second, sleep fragmentation/deprivation can not only aggravate pain and inflammation, but also dampen mood and pain inhibitory responses (e.g., Smith et al., 2007). Third, insomnia is linked to an increased incidence of widespread pain in the general population (Mork & Nilsen, 2012). Together, these findings make a strong case for treating insomnia co-occurring with chronic pain.
Recently, cognitive behaviour therapy originally developed for primary insomnia (CBT-I) has been used to address pain-related insomnia. This advance was motivated by the shift in thinking that comorbid insomnia should be treated as a problem in its own right (National Institute for Health, 2005). Moreover, evidence has accrued to suggest that primary and pain-related insomnia are similar in presentation (Okura et al., 2008) and that the cognitive-behavioural processes perpetuating primary insomnia also operate in pain-related insomnia (Tang et al., 2012a, 2012b). At least four randomised controlled trials (RCT) have been conducted to evaluate the utility of CBT-I in adults with chronic musculoskeletal pain (Currie et al., 2000; Jungquist et al., 2010), fibromyalgia (Edinger et al., 2005), and older adults with osteoarthritis (Vitello et al., 2009). Although significant improvements were achieved in a range of sleep outcome measures, improved sleep in these RCTs was not consistently followed by a reduction in pain and its associated distress and interference, contradicting the common assumption that pain and sleep are reciprocally linked. Simultaneous input to both problem areas may be required to effectively restore sleep and functioning in these individuals, justifying the development of a hybrid treatment approach.
The current study evaluated the utility of a brief intervention designed to simultaneously improve sleep and reduce distress and interference associated with chronic pain. The hybrid intervention concept pushes conventional boundaries that confine the development and application of treatments to well-defined diagnoses, particularly in psychology where the flexible combination of therapies designed for different disorders remains a novel practice. Consistent with the transdiagnostic perspective of research and treatment development (Harvey et al., 2004), the hybrid approach may provide a treatment option more suited to tackle challenges presented in clinical practice, where problems seldom occur in isolation.
Section snippets
Overview
Chronic pain patients with concomitant insomnia were randomly assigned to one of two conditions; to receive 4 weekly sessions of hybrid treatment (Hybrid Group; n = 10) or to keep a pain and sleep diary for 4 weeks, before receiving the hybrid treatment (Monitoring Group; n = 10). All participants were assessed before and after this 4-week period, enabling us to evaluate the efficacy of the hybrid treatment compared with symptom monitoring. Ancillary information about the hybrid treatment's
Participant characteristics
Table 2 presents the participants' characteristics by group. The sample represented a variety of pain conditions, including musculoskeletal pain (85%), osteoarthritis (35%), rheumatoid arthritis (10%), complex regional pain syndrome (10%), headache (10%), and fibromyalgia (5%), with more than half of the sample (55%) meeting criteria for ≥1 concurrent DSM-IV diagnoses (depression = 6, specific phobia = 5, substance dependence = 3, posttraumatic stress disorder = 2, generalised anxiety
Discussion
As a proof of concept, the findings above demonstrated the superiority of the hybrid CBT over symptom monitoring in treating chronic pain patients with clinical insomnia. The hybrid CBT was associated with greater improvements in participants' sleep quality. Although pain intensity – as expected – remained unchanged, the hybrid treatment was associated with greater reductions in pain interference, fatigue and depression than did symptom monitoring. The magnitude of these improvements was large,
Acknowledgements
This research was funded by a personal award to Nicole Tang from the National Institute for Health Research (Department of Health). The authors would like to thank Dr. Melanie Edwards, Jennifer Barley, Anthony Gabay, Rhian Tait and staff at the Pain Relief Unit, King's College Hospital for their assistance in patient recruitment.
References (47)
- et al.
Validation of the insomnia severity index as a clinical outcome measure for insomnia research
Sleep Medicine
(2001) - et al.
The validity of the hospital anxiety and depression scale: an updated literature review
Journal of Psychosomatic Research
(2002) - et al.
Medication Quantification Scale Version III: update in medication classes and revised detriment weights by survey of American Pain Society physicians
The Journal of Pain
(2005) - et al.
A cognitive model of insomnia
Behaviour Research and Therapy
(2002) - et al.
An open trial of cognitive therapy for chronic insomnia
Behaviour Research and Therapy
(2007) - et al.
The efficacy of cognitive behavioral therapy for insomnia in patients with chronic pain
Sleep Medicine
(2010) - et al.
Comparison of actigraphic, polysomnographic, and subjective assessment of sleep parameters in sleep-disordered patients
Sleep Medicine
(2001) Consensus on outcome measures for chronic pain trials
Pain
(2005)- et al.
Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache
Pain
(1999) - et al.
The phenomenology of the pre-sleep state: the development of the pre-sleep arousal scale
Behaviour Research and Therapy
(1985)
The contribution of pain, reported sleep quality, and depressive symptoms to fatigue in fibromyalgia
Pain
Comparison of sleep variables between chronic widespread musculoskeletal pain, insomnia, periodic leg movements syndrome and control subjects in a clinical sleep medicine practice
Sleep Medicine
An experimental study of attention, labelling and memory in people suffering from chronic pain
Pain
The Multidimensional Fatigue Inventory (MFI): psychometric qualities of an instrument to assess fatigue
Journal of Psychosomatic Research
Correcting distorted perception of sleep in insomnia: a novel behavioural experiment?
Behaviour Research and Therapy
Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art
Pain
Chronic spinal pain and physical-mental comorbidity in the United States: results from the national comorbidity survey replication
Pain
Recommendations for a standard research assessment of insomnia
Sleep
Measurement of pain by subjective report
A power primer
Psychological Bulletin
Cognitive-behavioral treatment of insomnia secondary to chronic pain
Journal of Consulting and Clinical Psychology
Psychological therapies for the management of chronic pain (excluding headache) in adults
Cochrane Database of Systematic Reviews
Overcoming insomnia: A cognitive-behavioral therapy approach
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Present address: Department of Psychology, University of Warwick, Coventry CV4 7AL, UK.