Sick and Tired: Understanding and Managing Sleep Difficulties in ...

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time and sleep quality were associated with negative affect and fatigue the following day. The effects of poor sleep on low mood and fatigue become more pronounced after two to three successive nights of poor sleep, suggesting that the effects of poor sleep are cumulative (Hamilton et al., 2008). These findings also indicate that poor sleep may lead to increased negative affect and fatigue, rather than the other way around. However, the study did not explore the effect of sleep on pain. A study which did explore the relationships between sleep and pain was conducted by Affleck et al (1998). Participants were asked to monitor their perceived pain, sleep, fatigue, and the amount of progress they felt they had made towards their rehabilitation goals, three times per day when prompted by the computer over a 30 consecutive day period. They revealed that poor sleep quality was associated with increased attention towards pain, reduced effort towards physical rehabilitation goals and increased pain severity the following day. The relationship between pain and sleep however did not appear to be bi-directional, as pain was not associated with poor sleep quality the subsequent night (Affleck et al., 1998). In support of these short term follow up findings, a longitudinal study exploring sleep and pain in patients with FMS over the course of one year, found that poor sleep quality at baseline was predictive of pain and sleep quality at one year, but baseline pain did not significantly predict sleep quality at one year (Bigatti, Hernandez, Cronan, & Rand, 2008). These findings support the conceptual framework of pain and sleep outlined in Chapter Two (Call-Schmidt & Richardson, 2003) suggesting that poor sleep may increase low mood and impair the person‟s ability to cope with subsequent pain. This in turn leads to increased attention towards the pain and pain severity as a result. Sleep disturbance may therefore have an important role in both the aetiology and maintenance of symptoms for patients with FMS, possibly through the lack of the restorative functions of good quality sleep and psychological impact. However, the findings of these studies are limited as only one of these studies used a standardised assessment of sleep quality such as the MOS-SS or PSQI, therefore the reliability and validity of the findings may be questioned. The potential difference in sleep disturbance may have important implications for treatment and further investigation into the exact nature of the sleep difficulties and factors that may be linked to the maintenance of sleep difficulties in people with FMS is needed. 45
Managing Sleep Disturbance in FMS Despite the chronicity of the difficulties experienced and the high prevalence of sleep disturbance in FMS (as is the case for patients with other chronic pain conditions), poor sleep quality often receives little attention in current treatment of the condition, and the most common treatment approach is the prescription of hypnotic or tricyclic antidepressant medications. Clinical trials have demonstrated the efficacy of these medications to reduce symptoms of sleep disturbance in the short term for FMS. For example, tricyclic medications have been found to improve sleep for one month (Moldofsky, 2002). However, there is little evidence of the efficacy of medications after prolonged use as the treatment effects disappear after discontinuation. The prolonged use of medications to aid sleep may also lead to impaired daytime functioning and may change the underlying sleep architecture. For example, benzodiazepines can reduce stages three and four of sleep (Morin, 1993) and indeed some people experience „rebound insomnia‟ after discontinuing their hypnotic medication, stating that their sleep quality is more impaired than before they started the medication. This can often lead to, or trigger dependence on taking hypnotic medications (Soldatos, Dikeos, & Whitehead, 1999). Common side effects of hypnotic and tricyclic medication (such as drowsiness and confusion) can also exacerbate other symptoms of FMS such as fatigue and cognitive difficulties, and may not be well tolerated by some patients (Lautenschlager, 2000; Moldofsky, 2002; Shaver et al., 1997). In addition to the limitations of pharmacotherapy, there is also wide variation in patients‟ adjustment to FMS, suggesting that psychological factors are important to the course and outcome of the condition (Burckhardt et al., 1992; Rao & Bennett, 2003). Consequently, there is an urgent need to explore the effectiveness of non-pharmacological interventions to improve sleep for people with FMS. Promising findings were observed in a pilot study of cognitive behaviour therapy to improve sleep quality for people with FMS (Edinger, Wohlgemuth, Krystal, & Rice, 2005). In comparison to participants randomized to receive sleep hygiene advice and usual care, participants who received the cognitive behaviour intervention on an individual basis for six weeks demonstrated almost a 50% reduction in the number of night-time awakenings experienced. A current full randomized controlled trial is underway to explore the efficacy of cognitive behaviour therapy, however some may argue that the costs of individual therapy may be too 46
Page 1 and 2:
Sick and Tired: Understanding and M
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Chapter Four. The Nature and Effect
Page 5 and 6:
References ........................
Page 7 and 8:
List of Tables Table 1. Participant
Page 9 and 10:
Co-authored Works Although the stud
Page 11 and 12: Acknowledgments This thesis would n
Page 13 and 14: Intellectual Property Rights There
Page 15 and 16: Confidential Material No participan
Page 17 and 18: The role of sleep in FMS appears to
Page 19 and 20: little information was available as
Page 21 and 22: Psychophysiologic insomnia which is
Page 23 and 24: and are less able to inhibit the pa
Page 25 and 26: widely applied in clinical practice
Page 27 and 28: of fewer tender points; usually bet
Page 29 and 30: Current Management Strategies The t
Page 31 and 32: also likely to depend on a number o
Page 33 and 34: deep sleep (stages three and four)
Page 35 and 36: Although sleep moves through the sl
Page 37 and 38: Figure 3. The Integrative Model of
Page 39 and 40: However, conducting a blood test is
Page 41 and 42: As sleep is a complex process invol
Page 43 and 44: Sleep Diaries Sleep diaries are a k
Page 45 and 46: pain). Lentz et al (1999) revealed
Page 47 and 48: These results have also been suppor
Page 49 and 50: (McCracken & Iverson, 2002) which s
Page 51 and 52: Figure 4. Conceptual model of the d
Page 53 and 54: Clinical Implications Despite the p
Page 55 and 56: Chapter Three. Sleep in FMS As high
Page 57 and 58: & Penzien, 2003), although alpha wa
Page 59 and 60: pauses in breathing indicative of s
Page 61: Relationships between Sleep and Pai
Page 65 and 66: may be possible to help patients im
Page 67 and 68: person to initiate an action (such
Page 69 and 70: and Nicassio et al (1995) only expl
Page 71 and 72: 1) Poor sleep quality, defined by t
Page 73 and 74: elow 0.7 are acceptable. Therefore
Page 75 and 76: heart disease (Epstein et al., 1999
Page 77 and 78: In order to explore the links betwe
Page 79 and 80: questionnaire 78 (77.2%) of the par
Page 81 and 82: efficiency, suggesting that partici
Page 83 and 84: Older age and longer length of illn
Page 85 and 86: Table 2. Correlations between demog
Page 87 and 88: Logistic Regression As 97% of the s
Page 89 and 90: in bed, participants may have devel
Page 91 and 92: Relationship between Negative Affec
Page 93 and 94: participants, who may be less likel
Page 95 and 96: emotional problems, increased pain
Page 97 and 98: eactions are most likely to be detr
Page 99 and 100: It has been suggested that the auto
Page 101 and 102: For both groups, participants were
Page 103 and 104: with and without chronic medical co
Page 105 and 106: As previously described on page 61,
Page 107 and 108: Figure 7. Scree plot for the explor
Page 109 and 110: Figure 8. Scree plot for the explor
Page 111 and 112: Table 6. Participant characteristic
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Table 7. Measures of central tenden
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CON = DBAS-10 Dysfunctional beliefs
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The Exp (B) values revealed that hi
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has explored the use of napping on
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It became clear, through the analys
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interventions. With this in mind, t
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The philosophy of phenomenology was
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Methods Participants were given a w
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Table 11. Interview schedule for th
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Rigour The interview transcripts we
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“The main symptom is this overwhe
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Theme Two. Inter-relationship betwe
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where I live, so I don‟t know, I
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Participants also described how the
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“XXXX (name of person) planned a
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A strong theme that emerged in this
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conducted at several time points, w
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Chapter Seven. Investigating the Ef
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activities because they no longer f
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Therefore as this was a feasibility
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Self-reported sleep quality was ass
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The progressive muscle relaxation (
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Exploring the baseline data, there
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Consequently, univariate analysis w
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There was no significant correlatio
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people with FMS (Perlis, Giles, Men
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The aim of this study was to explor
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observed in perceived overall sleep
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elaborated on in Chapter Six, which
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Four) revealed that global sleep qu
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Modifications to the Call-Schmidt a
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MBSR programme in people with FMS (
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diagnostic criteria for these sleep
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comprehensive measures to look at t
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References Abad, V. C., Sarinas, P.
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Brand, S., Gerber, M., Beck, J., Ha
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Crofford, L. J., & Demitrack, M. A.
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Goldenberg, D. L., Kaplan, K. H., N
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Johns, M. W. (2002). Sleep propensi
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Leung, Y. Y., Ho, K. W., Zhu, T. Y.
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Mease, P. J. (2005). Fibromyalgia s
Page 195 and 196:
symptoms in healthy subjects; Corre
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approach with illustration to the h
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Thomas, E. N., & Blotman, F. (2010)
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Yunus, M. B., Masi, A. T., & Aldag,
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Appendices Appendix A: Search Strat
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Sleep and Fibromyalgia Syndrome Con
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190
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The following questions relate to y
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There are lots of ways to try to de
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42. I try hard to prevent other thi
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During the past month have you had
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Appendix E: Published paper of Stud
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202
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204
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206
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Sleep and Fibromyalgia Syndrome Con
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Appendix H: Participant Questionnai
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Below are 10 statements reflecting
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The questions in this scale ask you
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Appendix I. Published Paper for Stu
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218
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220
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222
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Appendix K. Information Sheet and C
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Sleep in Fibromyalgia Syndrome Cons
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Appendix L: Letter of Ethical Appro
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Appendix M. Letter to GPs for Study
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What are the side effects of any tr
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Appendix O: Poster Advertising Stud
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Appendix Q: Participant Questionnai
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HAD Scale Read each item and place
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During the past month have you had
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Appendix R. Letter from Dr Mark Cro
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PUBLICATIONS Peer Reviewed Journal
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and panic-like episodes, Faculty of
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