Sleep Disorders

Sleep disturbances frequently accompany pain. Patients often experience longer sleep onset latencies, frequent nighttime awakenings, and overall shorter dura tion of sleep (Morin et al. 1998). Such disturbances are likely to result from having a painful condition (e.g., rheumatoid arthritis, fibromyalgia, back pain) and would therefore be categorized as a sleep disorder due to a general medical condition according to DSM-IV-TR diagnostic criteria. However, it should be noted that sleep disturbances can reciprocally exacerbate pain severity. For example, deficits in Stage IV sleep, even among healthy individuals, may increase rates of reported muscle tenderness, aching, and stiffness (Moldofsky and Scaris-brick 1976). When these deficits are corrected, the painful symptoms often disappear.

Other factors (e.g., comorbid depression) may also contribute to sleep disturbances among patients with pain. Abnormalities in the sleep patterns of patients with fibromyalgia have been noted to likewise contribute to sleep disturbances. Specifically, alpha-delta sleep—in which intrusion of low-voltage, rapid alpha waves occurs amid higher voltage, slow waves characteristic of delta sleep—has been associated with fatigue and the perception that the sleep is nonrestorative (see also section "Fibromyalgia" in Chapter 8, "Common Pain Disorders," of this book). Additionally, patients with chronic pain (e.g., neuropathic conditions) may experience sleep difficulties secondary to restless legs syndrome (Yunus and Aldag 1996). Restless legs syndrome is characterized by tingling, paresthesias, and cramping (often of the lower extremities) that arises when one reclines but is transiently alleviated by movement. This need for movement interferes with sleep. Recognition of and differentiating among the possible etiologies for sleep disturbances of patients with pain is critical, as treatment approaches are partly defined by underlying causes. For example, an antidepressant may be warranted in cases of depression, whereas a dopamine agonist or anticonvulsant may be warranted to mitigate sleep difficulties arising from restless legs syndrome.

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