Managing Pain & Sleep

Annie Miller, LCSW, is a licensed psychotherapist who specializes in the treatment of sleep issues at her Washington D.C.-based practice, DC Metro Sleep & Psychotherapy. She utilizes proven techniques, including Cognitive Behavioral Therapy for Insomnia (CBT-I), to help patients improve their sleep while managing other health issues.

We spoke to Annie about her work with patients managing their sleep while dealing with chronic pain. Her work highlights that it's possible to make progress in multiple areas of your health, without the need for medication.

To learn more, check out our Q&A with Annie below! 

You believe that chronic insomnia and pain go hand in hand. Can you expand on that?

Yes, in my work I do see many clients who struggle with both insomnia and chronic pain. I think of this connection in terms of how the brain is working. If your brain is in the fight-or-flight state often, you are going to have that stress show up in the body.

Pain and insomnia are warning signs. Perhaps you are dealing with a lot of stress in your life or unresolved trauma or anxiety. Feeling an increase in stress causes the amygdala to be in a heightened state. And this causes symptoms that can show up as insomnia or pain, and often both. The other very common symptom I see in clients is GI-related problems.

I work with clients to help them identify triggers for stress, trauma, and anxiety and work on relaxation to help reduce symptoms.

Why do some people have a hard time finding treatments that effectively address both conditions?

In my experience, when it comes to both insomnia and chronic pain, our first instinct is to treat these conditions from a medical-only perspective. Many patients try medication or procedures as a first-line treatment, while the brain is overlooked. Our model sets patients up to seek quick-fix type options and many don’t even consider therapy to treat these chronic conditions.

But there is a lot of evidence to show how the brain is essential in symptoms of insomnia and pain. Both CBT for insomnia and Pain Reprocessing Therapy are evidence-based and proven to be effective. I think people are starting to come around to behavioral strategies as a treatment for pain and insomnia, but it’s a big paradigm shift for many people.

In your experience, what does treating insomnia and pain through a behavioral framework like CBT-I offer that pharmaceutical options don’t?

What many people don’t realize about both insomnia and chronic pain is just how much your brain is involved. Medication can be helpful for many people. But I wouldn’t suggest medication for either insomnia or pain without trying therapy first, or in addition.

Medication can help manage symptoms, but it doesn’t treat the root cause. Changing your thoughts, behaviors, and habits around pain and sleep is the key to treating these conditions in the long term. Plus, these therapies don’t have the side effects that medications often do.  

You work with individuals who struggle with sleep and pain using therapies like CBT-I and Pain Reprocessing Therapy (RPT). Have you found that combining these therapies provides a faster or more effective outcome?

Yes, I work with clients to combine CBT-I and PRT often. If a client presents with both insomnia and problems sleeping, I typically suggest starting with CBT-I because studies show that CBT-I can help treat chronic pain, even without any other therapy.

But the majority of clients I see need more pain-focused work in addition to insomnia therapy and the combination is particularly effective. And successful CBT-I treatment can help clients be more open to chronic pain treatment. PRT focuses on the brain as the root cause of chronic pain, and this can be easier for clients to accept when they have already improved insomnia through cognitive and behavioral changes.   

Can CBT-I  help individuals dealing with pain and sleep issues, even without a formal diagnosis? 

Yes, absolutely. Many clients I work with aren’t formally diagnosed with insomnia. And of course, there is no testing for insomnia, it is a diagnosis that is based on reported symptoms.

For anyone who has trouble falling asleep, staying asleep, or waking up too early, CBT-I can help. Even for people wanting to regulate their sleep schedules or create more structure, CBT-i is effective. I believe CBT-I can help even more for insomnia that is not formally diagnosed. This is because many insomnia patients who go to the doctor are put on medication and that can complicate CBT-I treatment. And it’s often easier to start insomnia therapy without medication on board.

For someone struggling to achieve restful sleep, what would you recommend as a first step towards finding a solution?

For those struggling with sleep, I recommend seeking out a therapist trained in CBT-I It’s becoming more common that medical providers are suggesting CBT-I as a first-line treatment.

If therapy is not accessible, I would suggest trying some of the CBT-I basics. The three CBT-I rules that are most effective are making sure you wake up at the same time every day, using the bed only for sleep, and not lying in bed trying to sleep.

Can you share an example of a time you helped someone overcome their sleep issues when they were dealing with pain? What does the future look like for that person now?

I had one client in mind that had a lot of success in dealing with both chronic pain and insomnia. She was a very typical client in that she had a history of childhood trauma, was anxious, and described herself as a perfectionist.

She had been going through some stressful events in her life and she started having significant issues with insomnia and chronic pain. The symptoms were so acute that she couldn’t work, and many aspects of her life were on hold.

I started with CBT-I and she was able to get her sleep better relatively quickly- within a few weeks. And the pain improved a little bit just from getting better sleep. But then we started using PRT and her pain also got much better. She took to PRT easily and practiced the techniques on her own in between sessions.

Now, she is free of both pain and insomnia and our total treatment time was about 3-4 months. Not everyone improves this quickly, but I do see most people experience steady healing over time.

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Disclaimer: The information provided on this page should not be taken as medical advice and should not replace the advice of your healthcare provider. Always consult your physician before taking any new medication(s) or altering your current dosage.

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