Breaking the Vicious Cycle of Insomnia with Fibromyalgia
Insomnia is common in fibromyalgia patients, but there are ways to stop the increased pain that decreased sleep creates.
A diagnosis of fibromyalgia can seem forever ominous. With symptoms that include a combination of widespread pain, fatigue and cognitive difficulties, the disorder is known for its erratic disruption of everyday life.
And often the most difficult symptom of fibromyalgia is the one that drives all others: lack of sleep.
The power of sleep is gaining prominence with a recent study published in Arthritis & Rheumatology (March 2014) that showed nonrestorative sleep was the strongest independent predictor of new-onset widespread pain. While widespread pain is common among older adults, with fibromyalgia and other factors contributing to its development, the study confirms that the primary isolating contributor is lack of sleep.
As insomnia officially takes the lead among pain-inducing causes, the confirmed status is not news to Cleveland Clinic rheumatologist and fibromyalgia specialist Carmen Gota, MD.
“From our database of 305 fibromyalgia patients, 84.9 percent report unrefreshed sleep, and the mean number of hours of sleep nightly is 5.9,” says Dr. Gota. “Almost 50 percent of these patients scored 10 or higher on the Epworth Sleepiness Scale, an indicator of daytime sleepiness. In reality, all of our fibromyalgia patients experience poor sleep.”
Fibromyalgia entered Amanda Christian’s life over eight years ago. Symptoms of neuropathy led the central Ohio resident to specialists in Columbus who confirmed that she had 13 painful “hot spots” of the 18 official determined tender points used to identify the condition. Throughout the four years following diagnosis, Amanda tried many types of medications to break a cycle of pain, weight gain and depression.
“The best cure is to get up and keep moving, but when you hurt you don’t want to move, which makes it even worse,” Amanda says. “It’s a forever uphill battle.”
Amanda was about to fight even harder when she was involved in an auto accident that caused the death of her grandmother and severely injured two other family members. The result was an added diagnosis of post-traumatic stress disorder (PTSD), a condition known to significantly influence the symptoms of fibromyalgia.
“The PTSD and my depression seemed to trigger all of my fibromyalgia symptoms and worsened my overall condition—and lack of sleep was the biggest issue,” she says.
As Amanda tired of taking more pills to help get through each day, she traveled to Cleveland Clinic seeking a direction to empower real change.
After a comprehensive evaluation by Dr. Gota, she was able to take steps toward regaining control over debilitating symptoms.
“Dr. Gota didn’t just look at my fibromyalgia, but also the psychiatric help I needed for my PTSD symptoms,” says Amanda. “After reviewing my medications, she offered guidance on those I didn’t need anymore and those that would actually help me. Because I’m getting a full night’s sleep, I’m a lot more active. I feel like I have some control over my condition.”
Help for the haggard
Extensive data show that sleep of patients with fibromyalgia is interrupted. Research has confirmed that “alpha-wave intrusion” occurs during stage 3 of nonrapid eye movement (NREM) sleep, or the deeper level of sleep, resulting in an awakening or arousal into a lighter level of sleep.
“The way we approach a fibromyalgia patient is to look at things we can reverse; lack of sleep is one of those,” explains Dr. Gota. “While we first treat depression, anxiety, lack of exercise, stress and maladaptive attitudes about pain, if patients are still struggling with insomnia we look at medications that can help.”
Dr. Gota explains that using a low dose of a tetracyclic or tricyclic antidepressant at bedtime is often effective. “Yet, we prefer to start with a natural medication like melatonin, which has been demonstrated to increase the duration of sleep and decrease the time to fall asleep,” she says. “Antidepressants typically used to treat insomnia in fibromyalgia patients include amitriptyline (Elavil®), nortriptyline (Pamelor®, Aventyl®) and trazodone (Desyrel®).”
Adding extra assistance
Dr. Gota explains that a fairly large proportion of her patients have sleep apnea. Fibromyalgia and abnormal sleep breathing often occur together, and sleep apnea, which causes people to stop breathing while asleep, should be diagnosed and treated. Cognitive behavioral therapy and mindfulness techniques can also help patients relax and fall asleep.
Physical and aquatic therapy have also been beneficial for Amanda as she regains her footing against fibromyalgia. “I was determined to find ways to treat my condition and the motivation to live,” she says.