Are your PsA symptoms affecting your sleep, or is your trouble sleeping making your symptoms worse?

If psoriatic arthritis (PsA) has you tossing and turning at night, you’re not alone. 

Many people living with PsA have sleep difficulties, whether it’s from the pain and discomfort of PsA or other factors. If you have trouble sleeping, make a note of what your difficulties are. For example, are you having difficulty falling asleep or staying asleep? With this information your doctors will be able to help you get a better sleep by potentially adjusting your medications.  

Why sleep matters

Sleep promotes emotional wellbeing, brain function, hormone production and physical fitness. If you don’t get enough sleep your body does not have enough time to rest and repair.  Sleep disturbance is common among people with PsA. A lack of sleep can increase levels of stress hormones and aggravate flares. Also, if you have sleep issues, you may experience more pain. When you sleep, you make all those brain chemicals that you need to feel better. If you’re not rested you don’t have all of these good hormones, so it may be more difficult to cope with your pain. Poor sleep can also increase the risk of weight gain and obesity, which puts extra stress on your joints. It can also make it harder to concentrate, think clearly and carry out everyday activities such as driving. Prolonged lack of sleep can lead to anxiety and depression, or both. 

How much sleep do I need?

Most adults need about 7–8 hours of sleep per night, though this varies from person to person. Children tend to sleep more than adults, and older people tend to have lighter sleep.

Can medications affect sleep?

Some common PsA medications may also contribute to sleeplessness. Corticosteroids such as prednisone can cause insomnia, agitation, or depression. Another is hydroxychloroquine (Plaquenil) which can also cause sleep difficulties. Your doctor may recommend you take these medications early in the day to try and reduce the impact on your sleep. 

You may still experience sleep problems even if your PsA is under control. This might be due to other issues not related to your PsA such as stress-inducing changes in work or relationships. Sometimes, small lifestyle changes like cutting out caffeine in the evening, “lights out” on screen time an hour before bedtime can improve sleep. In other cases, learning relaxation techniques with a therapist or talking with a psychiatrist or psychologist about underlying problems may help.

If you have problems with your sleep, talk to your GP and/or rheumatologist so they can help assess and help you get a better sleep.

How can I improve my sleep?

Tips for good sleep include:

• Eliminate caffeine
• Avoid naps during the day
• Don’t drink alcohol
• Don’t eat a large meal near bedtime
• Exercise, but not too late in the evening
• Try to go to bed and get up at the same times every day
• Reserve your bedroom for sleep – no TV, mobile phones or even books. If you can’t sleep, get up after 20 minutes
• Go into another room and read or listen to music until you’re sleepy
• Avoid bright lights and electronic screens before bedtime
• Replace your mattress if it is old or uncomfortable. Read more about finding a new mattress.
• Changing the number or position of your pillows or choosing a soft or moulded pillow may be helpful if you have neck pain or upper back pain
• Some people find it helpful to sleep in a narrow soft foam collar
• Keep a sleep diary. Keeping a diary of your sleeping pattern can help your doctor spot things that disturb your sleep. It can include:
  • what time you go to bed and wake up
  • whether you got to sleep easily or not
  • any causes of disturbance, such as your mood, pain or fatigue
  • any caffeinated drinks 
  • your daytime activities.

Treatments for sleep problems

If your sleep problems continue, speak to your GP, rheumatologist or rheumatology nurse. They'll be able to offer more advice and prescribe medication if you need it. 

Medications

There are four main groups of medications that can be helpful. They’re most likely to have an effect when just one factor is causing your sleep disturbance. You may find it useful to take medications from more than one of these groups.

• Pain-relievers: Taking paracetamol just before going to bed can ease pain to allow you to get to sleep, but it's unlikely to last all night. Non-drowsy pain-relievers that include caffeine are unlikely to help you sleep. 
• Non-steroidal anti-inflammatory drugs (NSAIDs): Slow-release NSAIDs such as naproxen reduce pain and stiffness throughout the night. Although these medications have potential side effects, they can be very useful.
• Sedating antidepressant drugs: Some antidepressants, such as amitriptyline, have sedative effects, which means they make you sleepy. They may also reduce chronic pain. These medications aren't given as sleeping tablets but may improve your sleep as an added benefit. It's often advisable to take them a few hours before going to bed so that the effect has worn off by the morning. 
• Sedatives (hypnotics): Temazepam, zolpidem and zopiclone are given specifically to help you go to sleep, although they may not stop you waking during the night. They're sometimes called hypnotics. Doctors often advise against using sedatives because of the risk of dependence, which means you become addicted to them. There's also a risk of side effects, but they can sometimes be helpful for short-term use. 

Meditation mobile apps

Meditation apps like Smiling Mind, Insight Timer and Calm take you through guided meditations that can help improve sleep quality, reduce stress and/or anxiety and improve focus.

Cognitive behavioural therapy

Therapists and psychologists may be able to offer relaxation tips or cognitive behavioural therapy (CBT). A number of studies have investigated CBT as a treatment for sleep problems in people with chronic pain.

CBT is a psychological treatment based on the assumption that our thought patterns and reactions are learned and can therefore be changed. It aims to help you change any thoughts, feelings or behaviours that may be having a negative impact on sleep. It can be given either in group sessions or to individuals.

CBT uses a number of different techniques:

• Education teaches about sleep and the factors which help or disturb it (including sleep hygiene).
• Sleep restriction aims to improve sleep efficiency (the proportion of time you spend in bed sleeping). This is based on the principle that lying in bed awake for long periods makes sleep problems worse in the long term. Your bedtimes are changed to better reflect how much sleep you get.
• Stimulus control aims to help you link the bed only with sleep and sex. Common strategies include moving TVs out of your bedroom and not working or reading in bed.
• Cognitive therapy helps you spot and assess any negative thoughts and beliefs about your ability to sleep.
• Relaxation and imagery training can help you distract yourself from stimulating thoughts if you find it difficult to stop thinking about what happened during the day.

Some rheumatology clinics also offer evidence-based self-management groups which deal with fatigue and sleep issues. Ask if your rheumatology team offer this.