Fibromyalgia Support Group

Complex dynamics exist between chronic fatigue seen in fibromyalgia (FM) and chronic fatigue syndrome (CFS) and sleep. A good night sleep is the harbinger of a better well being and quality of life. Studies have suggested that poor sleep may exacerbate pain and fatigue or lower threshold for pain the next morning. Conversely, a better night sleep is also a predictor of improved pain or a better threshold for pain. Besides pain and fatigue, a close psychiatric relationship exists adding to the complexities in these patients. Patients with FM and CFS also score high on depression, anxiety or other psychiatric disorders. Some evidence of abnormalities in the neurohormones and neurotransmitters, have been found in FM, however, the exact mechanism of the disorders in not clear. Similarly the etiology of CFS is not clearly understood, but the possible mechanisms may include virus infection, stress and toxins.

Both subjective and objective studies have been done in patients with FM and sleep. The patients commonly complain of light and non-restorative sleep, with daytime fatigue. They also complain of insomnia defined as difficulty falling asleep, staying asleep and waking up too early, in addition to stiffness, pain and fatigue Polysomnographic studies confirm the subjective data; which shows that in fact the patients who report disturbed and non restorative sleep also have abnormal sleep patterns. The main abnormalities in those patients include: increased number of arousals, awakenings, and increased time of awakenings. Alpha waves in sleep seen in polysomnography are associated with quiet wakefulness; a phenomenon of alpha intrusion in deep sleep (also called deep or slow wave sleep) has been seen in patients with fibromyalgia, chronic fatigue syndrome and rheumatoid arthritis. There also seems to be a close association of this alpha intrusion with sleep disturbance, pain, energy and mood.

Patients with CFS have been found to have a very high incidence of sleep disorders including obstructive sleep apnea, restless legs syndrome and even narcolepsy. On the contrary, CFS patients do not present with objective sleep abnormalities, even though subjective complaints of sleep problems including severe unrefreshing sleep are present. Alpha intrusion characteristic of FM is not seen in patients with CFS. Some patients with CFS do have an arousal disorder, resulting in non-restorative sleep..

Ironically, patients’ complain of pain and fatigue, characteristic of both FM and CFS are usually met with skepticism and negative bias; this results in poor outcomes for the patients. For the diagnosis; the physicians must identify the pain and rule out other rheumatologic conditions. Patients’ complaints of poor sleep warrant close attention as well as treatment.

The treatment goals should take into account a multidisciplinary approach, with three essential components: control of pain; improvement in sleep and in many cases treatment of underlying depression or other psychiatric disorders.

To address sleep related issues, both non-pharmacological and pharmacological approaches can be used. The non-pharmacological approach includes maintaining relaxing bedtime rituals, regular bedtime, exercise and other life style related changes. For complaints of sleep related issues it is important for the patients to be referred to sleep specialists. The patients may be suffering from sleep disorders such restless legs syndrome, narcolepsy, or sleep related breathing disorders. Again, sleep disorders listed above are common is both CFS and FM. Diagnosis of the sleep disorders can be made using appropriate questionnaires and medical history. Further diagnosis of sleep disorders such as obstructive sleep apnea can be established using overnight polysomnography.

Pharmacological treatments, approved by the FDA, are available for patients with CFS and FM. However, the treatment regimen has to be customized for every patient as it relates to their tolerance and response to medications. Dosing in these patients need to be closely monitored. Any co-morbidities have to be carefully identified and treated accordingly for overall improvements in the symptoms of CFS and FM. 

Sleep Medine Textbook

Meir Kryger, MD