There is increasing evidence that individual beliefs, attitudes, and thoughts can initiate and perpetuate insomnia, and influence the duration and severity of chronic pain.
A study published in the Clinical Journal of Pain found that, while there are similarities in the pattern and severity of sleep disturbance between primary insomnia (insomnia in the absence of chronic pain) and pain-related insomnia, thought processes appear to play a significant role in the manifestation of pain-related insomnia.1
In a subsequent article, researchers showed that among patients with chronic pain, thoughts that are focused on pain before sleep were significantly associated with poorer sleep continuity.2
The precise prevalence of insomnia, however, depends on the specific case definition and the tool used for its assessment. Consequently, prevalence estimates have varied widely, ranging from 10% to 40% of the general population,3 with higher prevalence reported in individuals with chronic pain, including fibromyalgia, lower back pain and arthritis.4-6
Insomnia associated with chronic pain is thought to worsen the pain sensation and diminish coping ability. In addition, dysfunctional beliefs, attitude, and thoughts can all influence the pain sensation and impact sleep quality and insomnia.7
According to Nicole Tang, DPhil, C Psychol, Associate Professor in the Department of Psychology at Warwick University, UK, “Thoughts can have a direct and/or indirect impact on our emotion, behavior and even physiology. The way [we] think about sleep and its interaction with pain can influence the way we cope with pain and manage sleeplessness. Based on clinical experience, whilst some of these beliefs are healthy and useful, others are rigid and misinformed.”
Sleep-related “dysfunctional beliefs”, persistent anxiety and worry have been shown to be critical in mediating the perpetuation or exacerbation of insomnia.8
This association between cognition and insomnia suggests that insomnia can be manipulated by cognitive behavioral therapy (CBT), and that addressing dysfunctional beliefs when treating patients with comorbid insomnia and chronic pain might represent a promising approach.9
While the role of cognitive factors in the etiology of insomnia is well-recognized, few validated tools are available to evaluate patient-specific, sleep-related aspects of cognition relevant for therapy. To address this gap, the Dysfunctional Beliefs and Attitudes about Sleep (DBAS) scale consisting of 30 items was developed as a research and clinical tool to evaluate sleep-disruptive cognitive behaviors.10
Higher DBAS scores on this scale are indicative of higher levels of dysfunctional beliefs about sleep, whereas lower scores reflect improvement in sleep. A subsequent abbreviated 16-item DBAS scale provides a self-rating inventory and offers a more compact structure and ease of use compared to the 30-item scale.11
A recent study comparing the 30-item scale with the abbreviated version of the DBAS indicates limitations of the longer version in its psychometric properties and thus its usefulness as a quantitative measure for research and clinical application.12 In addition, the DBAS scale does not include a chronic pain component, limiting its application for this subpopulation.
A 10-item Pain-Related Beliefs and Attitudes about Sleep (PBAS) scale has recently been developed to assess pain-related dysfunctional beliefs and attitudes about sleep among 4 groups of individuals with chronic pain and insomnia, and administered as an extension of DBAS.13
According to Ester Afolalu, PhD candidate at the University of Warwick, and lead author on the study, “the PBAS [scale] is designed to be used in all chronic pain patients. The chronic pain patients described in this study all experienced non-malignant pain for at least 6 months, this excluded cancer pain but includes most other chronic pain conditions such as fibromyalgia, chronic back pain, arthritis, headaches, neuropathic pain, sickle cell pain.”
The self-administered PBAS scale, with instructions modeled on the established DBAS, was limited to 10 items for ease of administration in the clinical setting, and to improve user experience. In regards to the difference between the PBAS and DBAS scales, Afolalu explains that “the rationale for the PBAS scale is that sleep-related cognitions linked to chronic pain are different from those associated with primary insomnia (assessed by the DBAS). The PBAS is thus more suited than the DBAS to capture these specific beliefs about the pain-sleep interactions in chronic pain populations. Our findings further emphasis that the PBAS was actually a better significant predictor of sleep disturbance in chronic pain patients compared to the DBAS.”
Overall, the PBAS scale was shown to be reliable, with adequate internal consistency and temporal stability, and scores correlated with established measures of insomnia severity, including the Insomnia Severity Index scale, the Anxiety and Preoccupation about Sleep Questionnaire, and the DBAS.13
Results show that individuals who believe they are unable to sleep due to their pain were more likely to suffer from insomnia and a worsening of their pain. Scores on the PBAS scale were significantly lowered following CBT, indicating both the reliability of the scale and the positive impact of cognitive therapy.13
The development of the PBAS scale represents a positive advance in the management of chronic pain, as it offers a tool to assess the interaction between sleep, insomnia and chronic pain.
“The PBAS is designed to be used both in research setting and also in a clinical setting as a tool to identify and assess pain-related sleep thoughts that may require specific cognitive therapy,” explains Ester Afolalu, adding “it can also be used [by] clinicians as a measure of treatment progress when treating chronic pain patients with insomnia. The scale also showed great sensitivity to treatment when used to assess patients receiving a hybrid cognitive-behavioral therapy for both chronic pain and insomnia”.
This is even truer in light of current psychological treatments for chronic pain that have not addressed the sleep component, a gap now filled by the hybrid CBT.14 Results from this study may lead to the development of additional and improved cognitive therapies that will address both pain and insomnia.
Summary and Clinical Applicability
Among individuals with chronic pain, rigid and misinformed beliefs about sleep can have impact on the development of insomnia and worsening of the pain. The PBAS is the first scale to combine both pain and sleep, and provides a useful clinical tool to identify dysfunctional thoughts and monitor progress when treating individuals with insomnia and chronic pain. The incorporation of hybrid CBT simultaneously addresses the sleep and pain challenges to improve outcomes in patients with chronic pain.
Limitations and Disclosures
The study by Afolalu and colleagues identify that there were significant differences in age, insomnia severity, ethnicity and employment status of between the study populations and therefore further testing of the scale may be needed to confirm its universal application.
- Tang NK, Goodchild CE, Hester J, Salkovskis PM. Pain-related insomnia versus primary insomnia: a comparison study of sleep pattern, psychological characteristics, and cognitive-behavioral processes. Clin J Pain. 2012 Jun;28(5):428-436.
- Smith MT, Perlis ML, Carmody TP, Smith MS, Giles DE. Presleep cognitions in patients with insomnia secondary to chronic pain. J Behav Med. 2001 Feb;24(1):93-114.
- Mai E, Buysse DJ. Insomnia: Prevalence, Impact, Pathogenesis, Differential Diagnosis, and Evaluation. Sleep Med Clin. 2008;3(2):167-174.
- Bahouq H, Allali F, Rkain H, Hmamouchi I, Hajjaj-Hassouni N. Prevalence and severity of insomnia in chronic low back pain patients. Rheumatol Int. 2013 May;33(5):1277-1281.
- Roizenblatt S, Neto NS, Tufik S. Sleep disorders and fibromyalgia. Curr Pain Headache Rep. 2011 Oct;15(5):347-357.
- Abbasi M, Yazdi Z, Rezaie N. Sleep disturbances in patients with rheumatoid arthritis. Niger J Med. 2013;22(3):181-186.
- Jansson M, Linton SJ. Psychological mechanisms in the maintenance of insomnia: arousal, distress, and sleep-related beliefs. Behav Res Ther. 2007;45(3):511-521.
- Edinger JD, Fins AI, Glenn DM, et al. Insomnia and the eye of the beholder: are there clinical markers of objective sleep disturbances among adults with and without insomnia complaints? J Consult Clin Psychol. 2000;68(4):586-593.
- McCurry SM, Shortreed SM, Von Korff M, et al. Who benefits from CBT for insomnia in primary care? Important patient selection and trial design lessons from longitudinal results of the Lifestyles trial. Sleep. 2014;37(2):299-308.
- Morin CM, Stone J, Trinkle D, Mercer J, Remsberg S. Dysfunctional beliefs and attitudes about sleep among older adults with and without insomnia complaints. Psychol Aging. 1993;8(3):463-437.
- Morin CM, Vallières A, Ivers H. Dysfunctional beliefs and attitudes about sleep (DBAS): validation of a brief version (DBAS-16). Sleep. 2007 Nov;30(11):1547-1554.
- Chung KF, Ho FY, Yeung WF. Psychometric Comparison of the Full and Abbreviated Versions of the Dysfunctional Beliefs and Attitudes about SleepScale. J Clin Sleep Med. 2016 Jun 15;12(6):821-828.
- Afolalu EF, Moore C, Ramlee F, Goodchild CE, Tang NK. Development of the Pain-Related Beliefs and Attitudes about Sleep (PBAS) Scale for the Assessment and Treatment of Insomnia Comorbid with Chronic Pain. J Clin Sleep Med. 2016;12(9):1269-1277.
- Tang NK, Goodchild CE, Salkovskis PM. Hybrid cognitive-behaviour therapy for individuals with insomnia and chronic pain: a pilot randomised controlled trial. Behav Res Ther. 2012 Dec;50(12):814-821.