Tammy Applegate dreams of sleep – when she dreams, that is. Most nights, she can’t sleep soundly; pain rousts her four or five times. She turns over, repositions the pillow under one shoulder – the only position that offers some relief – and waits for slumber to overpower her discomfort. “Sometimes it takes me so long to get comfortable that I stay awake anywhere from 30 minutes to a couple of hours,” says the Fort Worth, Tex., mother of four, who has mixed connective tissue disease and requires sleep treatments to resolve her issues with pain and sleep.

She’s got plenty of company. Insomnia – broadly defined as having trouble falling or staying sleep – affects anywhere from 10 to 40 percent of American adults, at least intermittently, according to population studies. It’s estimated that some 10 to 15 percent have long-term sleep problems (lasting more than a month).

If you have problems with pain and sleep that seem intractable, don’t lose hope.  There are ways to improve your chances of getting a good night's rest. 

What Goes Wrong

Adults usually need between seven and nine hours of sleep a night. Ideally, that sleep comes in cycles, played out in roughly 90-minute segments throughout the course of a night. It includes rapid eye movement (REM) sleep, in which you dream, and four stages of non-REM sleep. First you enter several stages of non-REM sleep, descending from stages 1 and 2 into stages 3 and 4 – the deeper and more restorative stages. You then resurface and enter REM sleep. Then another 90-minute cycle starts.

Insomnia – the disruption of the sleep cycle – comes in two forms. Secondary insomnia is a side effect of another condition, illness or behavior (see “Treating Underlying Conditions”). In addition to arthritis or fibromyalgia, for example, it can be caused by poor sleep hygiene; stress; and a range of medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids and, for some people, statins (such as Lipitor and Zocor). 

With primary insomnia, however, there is no clear cause as to why people can’t sleep. It may be triggered by a major stressful event or by disruptions in your sleep routine (caused by travel or work). Researchers are also examining whether some people simply are predisposed to insomnia.

Even normal aging takes a toll: As we grow older, we naturally get less restorative sleep and are more likely to wake up in the night – although the amount of sleep we need doesn’t change.

Just worrying about insomnia can make it worse, so that it becomes a self-fulfilling prophecy, says Art Spielman, PhD, a longtime sleep researcher and psychology professor at The City College of The City University of New York. “If you think you are not going to fall asleep, you don’t fall asleep,” he says.

The Sleep/Pain Cycle

Achieving restful sleep can be particularly difficult for people like Applegate who have chronic pain. “Pain is a lump of coal under your mattress,” says Spielman. “Even when you’re asleep, the mind can register pain.”

People may notice obvious signs of pain and sleep problems, such as not being able to fall asleep or waking up frequently due to discomfort, says Michael Smith, PhD, director of the sleep psychophysiology laboratory at Johns Hopkins University in Baltimore. Or – and Smith believes this may be more disabling – they have disruptions in the sleep cycle itself so that they sleep but don’t get enough deep sleep. They may be aroused during sleep and pushed from deep sleep into a lighter stage without ever knowing it. “Their deeper sleep is disrupted by arousals or outright awakenings,” Smith says. “They may sleep 10 hours but feel groggy and unrefreshed the next day.”

That also may be the case for people with fibromyalgia, who tend to have abnormalities in deeper-stage sleep. Researchers have explored whether sleep disorders cause the pain of fibromyalgia or vice versa, but it’s still not clear.

Inflammation, pain and the immune system all appear to be impacted to some degree. In a 2006 study by the University of California, Los Angeles, researchers evaluated the effects of sleep deprivation on 30 healthy adults. After only one night, participants who were kept awake from 11 p.m. to 3 a.m. experienced an increase in inflammatory chemicals the body produces in autoimmune diseases, such as rheumatoid arthritis (RA).

When you can’t sleep because of pain, the process can become a seemingly endless loop. A recent study by Smith found that fragmented sleep resulted in both increased pain sensitivity and more spontaneous pain. Bernard Rubin, chief of rheumatology at the University of North Texas Health Science Center in Fort Worth, says, “It gets to be a vicious cycle. If you don’t sleep well, pain is accentuated.”

That’s because sleep doesn’t just reboot your system, refreshing your body and mind for the next day. It also helps repair your body.

Growth hormone, which the body releases most often in our deepest stages of sleep, helps heal tiny muscle tears that occur naturally during the course of the day, says Daniel Clauw, MD, a rheumatologist and director of the Chronic Pain and Fatigue Research Center at the University of Michigan. As we age, the amount of growth hormone that is secreted declines, along with the amount of time we spend in deep sleep, although scientists aren’t sure if one causes the other. But if your deep sleep is disrupted, your body may not secrete enough growth hormone to heal itself. 

Your waistline may also be at risk if you can’t sleep. A recently published analysis of the Nurses’ Health Study, involving data from nearly 70,000 women, found that those who slept no more than six hours nightly faced a 12 percent higher likelihood of gaining 33 pounds during the 16-year study. The risk jumped to 32 percent if they slept five hours or less. Because the shortchanged sleepers didn’t consume any more calories, the cause remains unknown, according to Sanjay Patel, MD, an assistant professor of medicine at Case Western Reserve University in Cleveland, who led the study. One theory is that sleep deprivation may alter the body’s metabolism.

Ongoing sleep deprivation has also been linked to chronic health problems such as diabetes or hypertension, although the specific mechanisms remain unclear, says Dr. Clauw. “There’s almost no biological function that sleep doesn’t affect in a fairly profound way,” he says. “We used to think of poor sleep as a nuisance, but it’s a legitimate health problem.”