Abstract
Objective:
Dysfunctional beliefs about sleep and pain are common among individuals experiencing recurrent pain and may inadvertently maintain insomnia symptoms. Thus, the present study sought to determine the level at which pain-related beliefs about sleep may predict insomnia and assess whether pain-related beliefs about sleep predict attitudes towards insomnia treatment above other known factors.
Patients/methods:
Data consisted of 999 individuals (M age = 44.18, 45.75% male) who participated in an online study about sleep and health across the lifespan. Beliefs about sleep and pain were measured via the pain-related beliefs and attitudes scale (PBAS) while insomnia and pain were assessed using the insomnia severity index (ISI) and a visual analogy scale, respectively. Attitudes towards insomnia treatment was measured using the insomnia treatment acceptability scale (ITAS).
Results and conclusion:
A score of 6.10 out of 10 on PBAS optimized sensitivity (66.40%) and specificity (66.90%) for insomnia classification. Pain-related beliefs about sleep predicted treatment acceptability of both behavioral (β = .46, p <. 001) and pharmacological treatments (β = 0.50, p < .001) over and above insomnia symptoms, pain severity, or sleep-self efficacy. Results underscore the importance of cognitive-behavioral factors as it relates to insomnia among individuals with comorbid pain and are relevant to the developments of models which seek to understand attitudes towards insomnia treatment.
Keywords: Insomnia, Recurrent pain, Dysfunctional beliefs, Treatment acceptability
Sleep disorders and recurrent pain frequently co-occur [1]. According to one estimate, insomnia is nearly 18 times more prevalent among individuals with recurrent pain relative to pain-free patients [2]. Comorbid insomnia and pain is not only common but is also associated with significant morbidity including higher rates of depression, anxiety, catastrophizing, suicidal ideation, and disability [3,4].
While pain can precipitate the onset of insomnia, insomnia often becomes an independent chronic condition [5]. Additionally, even though insomnia and pain are bi-directionally related, a growing body of research suggests that insomnia is a stronger and more consistent predictor of pain than vice versa [6,7]. Intervening on sleep may therefore be an important, but overlooked, avenue for improving pain and quality of life among individuals experiencing pain.
1. Pain-related beliefs about sleep
Dysfunctional beliefs about sleep perpetuate insomnia by increasing pre-sleep cognitive and physiological arousal and promoting sleep-interfering behaviors [8]. For this reason, identifying and challenging dysfunctional beliefs about sleep has been one of the core components of cognitive behavioral therapy for insomnia (CBT-I), the first-line treatment for insomnia recommend by several professional organizations [9,10]. Not only does CBT-I improve sleep overall but it is also effective in decreasing dysfunctional beliefs about sleep [11], with some evidence suggesting that dysfunctional beliefs about sleep mediates the effect of treatment [12,13].
Individuals with comorbid insomnia and recurrent pain are well-known to hold strong beliefs about the interaction between sleep and pain. This may include viewing sleep disturbance as an inevitable consequence of pain or catastrophizing about one’s ability to manage pain following a poor night of sleep [14,15]. Unfortunately, these beliefs may not be adequately captured via existing measures such as the commonly used dysfunctional beliefs about sleep scale (DBAS) [16]. The pain-related beliefs and attitudes scale (PBAS) was specifically developed to address this gap by assessing dysfunctional and maladaptive beliefs about the interaction between sleep and pain held by patients experiencing comorbid insomnia and pain [17]. The scale includes items such as, “I know that I can’t sleep through the night because the pain will wake me up” and “unless I get rid of the pain, I won’t sleep well.” In their initial development of the scale, Afolalu et al. [17] found that distorted pain-related beliefs about sleep are related to, but distinct from, dysfunctional beliefs about sleep and associated with higher levels of insomnia severity and pain interference. The generalizability of these findings, however, is somewhat limited given that participants only consisted of individuals with pain receiving care from hospital-based pain clinics. Further research is needed to examine whether the PBAS can differentiate levels of pain-related beliefs about sleep among community-based samples. Additionally, the identification of a cut-off point at which the scale may detect clinical levels of dysfunctional beliefs may enhance its clinical use.
2. Attitudes towards insomnia treatment
Pain-related beliefs about sleep may also uniquely shape patients’ attitudes about insomnia treatment. For example, a prior study of primary care patients found that dysfunctional beliefs about sleep were the strongest predictor of attitudes towards a behavioral treatment of insomnia followed only by attitudes towards medication treatment and sleep self-efficacy [18]. In addition to predicting interest in insomnia treatment, dysfunctional attitudes towards sleep are important indicators of adherence to insomnia treatment recommendations with greater levels of dysfunctional beliefs about sleep being associated with poorer adherence to sleep restriction and stimulus control guidelines [19]. These findings extend to individuals with comorbid pain where treatment perceptions were found to be a key predictor of CBT-I session attendance and drop-out rates [20]. Thus, patients’ beliefs about their sleep-pain symptoms may be an important, but overlooked, indicator of their attitudes towards insomnia treatment.
3. Present study
The main aims of the present study were three-fold and included: a) examining whether individuals with varying pain and insomnia presentations report different levels of pain-related beliefs about sleep, b) determining the cutoff point at which the pain-related beliefs about sleep on the PBAS can optimally detect the presence of clinically meaningful insomnia symptoms for individuals who endorse pain, and c) examine whether pain-related beliefs about sleep predict attitudes towards behavioral and pharmacological treatments for insomnia over and above known predictors of treatment acceptability (e.g., insomnia severity, self-efficacy). Individuals with both recurrent pain and insomnia were hypothesized to endorse the highest levels of pain-related beliefs about sleep relative to other clinical presentations. Additionally, among individuals experiencing insomnia and recurrent pain, pain-related beliefs about sleep were hypothesized to be a stronger predictor of insomnia treatment acceptability than insomnia or pain severity.
4. Methods
4.1. Study design
Data for the present study were drawn from a larger online study which investigated sleep and related health behaviors. The research study was approved by Virginia Commonwealth University’s institutional review board. Participants were recruited via Amazon’s Mechanical Turk (MTurk) and compensated $1.00 for their time. Inclusion criteria were minimal and consisted of: a) residence within the US and b) gender such that an equal number of men and women were enrolled. An age validity check and an instructional manipulation check were used to ensure the collection of valid, high-quality, data. Data collected via MTurk has been shown to be as reliable as in-person data collection, with no differences in the quality of the data based on the compensation rate [21].
4.2. Measures
4.2.1. Insomnia
Insomnia symptoms were measured using the Insomnia Severity Index (ISI) [22]. The ISI consists of seven items assessing the presence and severity of insomnia symptoms. Each item is scored on a 4-point Likert scale. Total scores range from 0 to 28, with higher scores indicating greater insomnia severity. Scores greater than or equal to 10 have been identified as optimally detecting insomnia in community samples [23]. Cronbach’s alpha for the ISI in the current sample was .82.
4.2.2. Attitudes towards insomnia treatment
The Insomnia Treatment Acceptability Scale (ITAS) was used to examine participants’ attitudes towards insomnia treatment [24]. The ITAS consists of two subscales each consisting of nine items. One subscale measures participants’ attitudes towards medication for insomnia (ITAS-M), while the other subscale measures attitudes towards behavioral treatment (ITAS-B). For each subscale, items associated with treatment acceptance, willingness to adhere to the treatment, perceived efficacy, and anticipated side effects are rated on visual analog scales ranging from 0 to 100. The average of each of the nine items from each subscale is used to produce two total scores. Cronbach’s alpha for the ITAS-M and ITAS-B was 0.91 and 0.90, respectively.
4.2.3. Pain
Consistent with previous researching using MTurk to screen individuals for recurrent pain [25], as well as the International Association for the Study of Pain’s definition of recurrent pain [26], participants were classified as having recurrent pain if they responded yes to the following question: “have you experienced pain on most days during the past three months or longer?”. Additionally, average pain severity during the last two weeks was rated on a visual analog scale ranging from 0 (no pain) to 100 (pain as bad as you can imagine). Visual analog scales from 0 to 100 have been well-validated as measures of subjective pain with no meaningful differences existing between paper and computer/phone-based visual analog scales [27].
4.2.4. Beliefs about pain and sleep
Beliefs about sleep and pain were measured using the Pain-Related Beliefs and Attitudes about Sleep scale (PBAS) [17]. This newly developed measure asks respondents to rate their level of agreement with 10 statements on an 11-point Likert scale from 0 (strongly disagree) to 10 (strongly agree). Sample items include “I know I can’t sleep through the night because the pain will wake me up,” or “I won’t be able to cope with the pain unless I sleep well.” The total score on the PBAS is calculated by averaging all items, with higher scores representing greater dysfunctional beliefs regarding the sleep and pain relationship. Cronbach’s alpha for the PBAS in the current sample was .98.
4.3. Sleep Self-Efficacy
Self-efficacy was measured using the Sleep Self-Efficacy scale (SSE; [34]). The scale consists of nine items in which participants rate their confidence in accomplishing sleep-related behaviors on a 5-point Likert-scale from 1 (not at all confident) to 5 (very confident). Higher scores on the SSE corresponds to greater sleep self-efficacy. Cronbach’s alpha on the SSE scale in the present sample was .87.
4.4. Data analysis
Differences in PBAS scores among participants with and without insomnia and with and without recurrent pain were analyzed via a 2 (insomnia status) × 2 (pain status) ANOVA, where the presence of insomnia was operationalized as an ISI score greater than 10 and the presence of recurrent pain was defined as an endorsement of pain on most days during the past three or more months. Next, a receiver operating curve (ROC) analysis was used to determine the clinical cut-off score at which the PBAS would be associated with the optimal level sensitivity and specificity in detecting insomnia based on an ISI ≥10. Finally, the association between pain-related beliefs about sleep and insomnia treatment acceptability among individuals with a high risk for insomnia (ISI ≥10) was examined using two hierarchical linear regression analyses. Insomnia severity on the ISI, sleep self-efficacy on the SSE, and self-reported pain intensity were all entered in block 1 while participants’ PBAS score was entered in block 2. Finally, the total score on either the behavioral or medication subscale of the ITAS was entered as the respective criterion variable.
5. Results
5.1. Descriptive statistics
The present study consisted of 999 individuals. Participants were predominately middle-aged (M = 44.18, SD = 16.23, range = 19–82) and White (72.77%). Participants’ average ISI score fell within the sub-threshold clinical range (M = 9.69, SD = 6.36) with 52.85% of participants scoring above the clinical cut-off for insomnia on the ISI. Over a fourth of participants (27.13%) reported using sleep medications one or more times a week. Average pain severity was also elevated (M = 39.46, SD = 29.23) with nearly half of participants (49.95%) endorsing recurrent pain. Participants who endorsed recurrent pain reported higher levels of pain intensity (n = 499, M = 57.68, SD = 22.38) than participants without recurrent pain [n = 500, M = 21.27, SD = 23.69, t(997) = 25.15, p < .001]. Additionally, participants with recurrent pain endorsed significantly higher levels of pain-related beliefs and attitudes about sleep (M = 6.16, SD = 2.32) than participants without recurrent pain [M = 2.98, SD = 2.78; t(997) = 19.65, p < .001]. Overall acceptability towards either a behavioral or medication treatment for insomnia was rated as slightly above neutral. Complete descriptive statistics are presented in Table 1.
Table 1.
Participant descriptive statistics (n = 999).
| Mean (SD)/Frequency (%) | |
|---|---|
| Age | 44.18 (16.23) |
| Gender | |
| Male | 457 (45.75%) |
| Female | 477 (47.75%) |
| Other | 65 (6.51%) |
| Race/Ethnicity | |
| White | 727 (72.77%) |
| African American/Black | 182 (18.22%) |
| Latino | 48 (4.80%) |
| Asian American | 78 (7.81%) |
| Other | 24 (2.40%) |
| Education (% Bachelor’s or higher) | 739 (73.97%) |
| ISI | 9.69 (6.36) |
| SSE | 27.89 (5.42) |
| Pain Severity VAS | 39.46 (29.23) |
| ITAS-B | 67.64 (16.10) |
| ITAS-M | 61.72 (19.72) |
Note. Participants could endorse more than one race/ethnicity. ISI = Insomnia Severity Index, ITAS-B = Insomnia Treatment Acceptability Scale - Behavioral, ITAS-M - Insomnia Treatment Acceptability Scale - Medication, SSE = Sleep Self-Efficiency.
5.2. Pain-related beliefs about sleep
A 2 × 2 ANOVA examined differences in pain-related beliefs about sleep among individuals with and without insomnia and recurrent pain. The means and standard deviation of participants’ PBAS scores by group are presented in Table 2. The ANOVA produced as significant main effect for recurrent pain F(1, 998) = 167.75, p < .001) indicating that individuals with recurrent pain endorsed higher levels of pain-related beliefs about sleep (M = 5.63) than individuals without recurrent pain (M = 3.49). Similarly, there was a main effect for insomnia F(1, 998) = 207.89, p < .001, whereby participants with insomnia endorsed higher scores on the PBAS (M = 5.75) relative to individuals without insomnia (M = 3.37). By contrast, there was no insomnia × pain interaction effect F(1, 998) = 2.17, p = .14.
Table 2.
Means and standard deviations of participants’ PBAS scores by insomnia and pain presentation (n = 999).
| Recurrent Pain | No Recurrent Pain | |||||
|---|---|---|---|---|---|---|
| n | Mean | SD | n | Mean | SD | |
| Insomnia | 375 | 6.69 | 1.86 | 153 | 4.80 | 2.72 |
| No Insomnia | 124 | 4.56 | 2.79 | 347 | 2.17 | 2.41 |
5.3. Clinical cut-off
A ROC analysis examining the ability of the PBAS to predict insomnia among individuals reporting recurrent pain produced an area under the curve of 0.73, p < .001, with a 95% confidence interval ranging from 0.68 to 0.79. Additionally, an inspection of the ROC curve indicated that a clinical cut-off of 6.10 on the 11-point Likert scale optimized sensitivity (66.40%) and specificity (66.90%) for insomnia classification, thus resulting in a true-positive rate of 66.40% and a false-negative rate of 34.10%. The ROC curve is depicted in Fig. 1.
Fig. 1.
ROC Curve of the PBAS for Classifying Insomnia
Note. The point closest to the top left-hand corner represents the optimal compromise for sensitivity and specificity in terms of the PBAS classifying insomnia status.
5.4. Pain-related beliefs about sleep and attitudes towards insomnia treatment
A correlation matrix of the clinical factors and their association with attitudes towards treatment for individuals who screened positive for insomnia (i.e., ISI ≥10) is presented in Table 3. In Block 1 of the hierarchical linear regression, insomnia severity (p = .02), pain severity (p = .002), and sleep self-efficacy (p < .001) each predicted treatment acceptability of behavioral treatment for insomnia (ITAS-B). In Block 2, participants’ PBAS scores were also significantly associated with treatment acceptability (p < .001) and accounted for an additional 10% of the total variance. Insomnia and pain severity were no longer significant predictors of behavioral treatment acceptability when pain-related beliefs about sleep were included in the regression model.
Table 3.
Associations among clinical characteristics and insomnia treatment preference.
| 1 | 2 | 3 | 4 | 5 | |
|---|---|---|---|---|---|
| 1. PBAS | – | ||||
| 2. ISI | .24* | – | |||
| 3. Pain Severity | .62* | .17* | – | ||
| 4. SSE | .43* | −.02 | .41* | – | |
| 5. ITAS-B | .39* | .12* | .32* | .44* | – |
| 6. ITAS-M | .46* | .19* | .42* | .51* | .56* |
Note.
p <.001.
PBAS = Pain-Related Beliefs and Attitudes about Sleep, ISI = Insomnia Severity Index, SSE = Sleep Self-Efficacy, ITAS-B = Insomnia Treatment Acceptability - Behavioral, ITAS-M = Insomnia Treatment Acceptability - Medication.
Among participants who screened positive for insomnia (i.e., ISI ≥10), insomnia severity (p = .01), pain severity (p < .001), and sleep self-efficacy (p < .001) each predicted treatment acceptability of medication treatment for insomnia as measured by the ITAS-M. The addition of pain-related beliefs about sleep in Block 2 accounted for an additional 12% of the total variance. Complete results of both hierarchal linear regressions predicting insomnia treatment preferences are presented in Table 4.
Table 4.
Hierarchical Linear Regressions Predicting Acceptability of a) Behavioral and b) Medication Treatment for Insomnia.
| a) Behavioral | F | R 2 | Δ R2 | β |
|---|---|---|---|---|
| Block 1 | 23.94*** | .27 | .27 | |
| ISI Total Score | .15* | |||
| Pain Severity | .21** | |||
| SSE | .35*** | |||
| Block 2 | 28.32*** | .37 | .10 | |
| ISI Total Score | .10 | |||
| Pain Severity | −.06 | |||
| SSE | .26*** | |||
| PBAS Total Score | .46*** | |||
| b) Medication | F | R 2 | Δ R2 | β |
| Block 1 | 37.49*** | .36 | .36 | |
| ISI Total Score | .15* | |||
| Pain Severity | .29*** | |||
| SSE | .38*** | |||
| Block 2 | 45.20*** | .48 | .12 | |
| ISI Total Score | −.01 | |||
| Pain Severity | .90 | |||
| SSE | .29*** | |||
| PBAS Score | .50*** |
Note.
p≤.001,
p≤.01,
p<.05.
ISI = Insomnia Severity Index, SSE = Sleep. Self-Efficacy; PBAS = Pain-Related Beliefs and Attitudes about Sleep.
6. Discussion
Findings from the present study build on the initial validation efforts by Afolalu et al. [17] in several important ways. To our knowledge, this was the first study to use the PBAS among a community-based sample of individuals with and without recurrent pain. Our findings suggest that the PBAS scores are higher among individuals experiencing recurrent pain and insomnia. Additionally, this finding is consistent with previous work which found that individuals experiencing both conditions are prone to maladaptive coping strategies such as heightened levels of pain catastrophizing, worry, or rumination [28,33]. Given the association between pain-related thoughts about sleep and pain interference, patients’ maladaptive cognitions regarding their sleep-pain symptoms may contribute to disability.
Secondly, the PBAS appears to adequately tap into beliefs which differentiate those with insomnia from good sleepers. That is not to say that the PBAS should serve as a diagnostic tool for insomnia, instead it suggests that patients with recurring pain who obtain a PBAS score of 6.10 or higher are the most likely to experience comorbid clinical insomnia. Such patients may particularly benefit from behavioral sleep interventions which target behavioral and cognitive symptoms which may maintain both insomnia and chronic pain. Despite this promising finding, the relatively high false-positive rate suggests that a fair number of individuals with recurrent pain experience distorted beliefs about sleep and pain without experiencing clinically significant insomnia symptoms. This underscores the behavioral components involved in the development and maintenance of insomnia (e.g., prolonged time in bed, excessive daytime napping, inactivity) and aligns with research indicating that reductions in dysfunctional beliefs following insomnia treatment do not mediate sleep-related treatment gains [29].
Pain-related beliefs about sleep may be a more useful indicator of engagement in treatment than of treatment outcomes. While patient attitudes towards insomnia treatment are a known predictor of treatment adherence [20], knowledge regarding factors which predict attitudes towards treatment for individuals with co-occurring pain are more limited. This gap in the literature is particularly notable given that CBT-I can be perceived as an arduous treatment with relative high rates of non-adherence in some studies [30]. Our finding that pain-related beliefs about sleep predict attitudes about insomnia treatment over and above insomnia or pain severity suggests that it warrants greater clinical attention. In line with the cognitive-behavioral model of insomnia [24], maladaptive beliefs about the relationship between sleep and pain may promote the development of maladaptive habits which maintain insomnia. Even though such cognitions may predispose individuals to experience sleep difficulties, a recent qualitative study of CBT-I among veterans with comorbid pain indicated that, contrary to expectations, pain was not identified as a barrier to treatment adherence or effectiveness [31]. Finally, the fact that sleep self-efficacy remained a significant predictor of attitudes towards insomnia treatment suggests that it should be enhanced prior to the start of behavioral treatments using strategies such as motivational interviewing.
Interestingly, pain-related beliefs about sleep were a nearly equally strong predictor of attitudes towards both pharmacological and behavioral treatments for insomnia. This is despite the fact non-pharmacological approaches to insomnia often tend to be favored by patients and often explicitly target dysfunctional beliefs related to sleep [32]. It may be that the desire for adequate insomnia treatment overrides specific treatment preferences, particularly if pharmacological options are believed to provide more immediate relief [18].
6.1. Limitations
The present study contained some limitations. Cross-sectional data were utilized to examine study objectives; therefore, additional research is needed to assess how pain-related beliefs about sleep are related to clinical symptoms over time. Additionally, there was no data available regarding specific pain diagnoses or pain locations. Lastly, the study examined pain and insomnia in a community sample of individuals with relatively high rates of sleep medication use rather than a clinical sample receiving treatment from a pain clinic, thus, further information is needed to determine whether findings generalized to individuals with concurrent insomnia and pain diagnoses Despite these limitations, the study used a large sample of adults in order to provide a comprehensive view of pain beliefs about sleep within the context of chronic pain and insomnia.
6.2. Conclusions
Insomnia and chronic pain are common co-occurring conditions with interactive effects. Evidence from the present study suggests that pain-related beliefs about sleep may serve as a useful tool for detecting clinical levels of dysfunctional beliefs pertaining to sleep and pain, predicting treatment acceptability, and as serving as a potential modifiable target for cognitive-behavioral sleep interventions. Additional information regarding pain-related beliefs about sleep may be clinically useful for developing brief, insomnia interventions among patients with co-occurring pain.
Acknowledgements
Funding: Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under Award Number K23AG049955 (PI: Dzierzewski).
Footnotes
CRediT authorship contribution statement
Scott G. Ravyts: Conceptualization, Formal analysis, Writing – original draft, Writing – review & editing. Elliottnell Perez: Writing – original draft, Writing – review & editing. Joseph M. Dzierzewski: Funding acquisition, Writing – review & editing, Supervision.
Declaration of competing interest
The authors have no conflict of interest to report.
Data availability statement
The data that support the findings of this study are available from the corresponding author, JD, upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author, JD, upon reasonable request.