This information should only be used for educational purposes in consultation with your physician. Good Sleep Health Inc assumes that you have read and understood the Terms of Use Agreement.
Author: Ron Cridland, MD
Fibromyalgia (FM) is characterized by widespread body pain and tenderness, sleep disturbance, fatigue, and depressed mood. Between 80-90% of patients are women. Chronic Fatigue Syndrome (CFS) is characterized by severe, disabling fatigue associated with impairment of concentration and short-term memory, sleep disturbance, depressed mood, and musculoskeletal pain. About 75% of patients are women.
Both FM and CFS are generally considered incurable by most medical professionals. However, it is well recognized that nonrestorative sleep is the most common complaint in these conditions with up to 95% of patients reporting sleep difficulties. Ironically, neither The American College of Rheumatology nor the Chronic Fatigue Syndrome Study Group recommend screening patients for sleep disorders or any sleep testing. They don’t even recommend asking patients how many hours of sleep they get!
A study published by Zoe Gotts et al in the British Medical Journal in 2013 on 343 patients with CFS showed 29% had Obstructive Sleep Apnea and 5% had Periodic Limb Movement Disorder. Overall, 81% had either insomnia or hypersomnia. A study on 40 patients with FM by G. Prados et al published in Clinical & Experiment Rheumatology Online in 2013 showed that 61% of men and 31% of woman had moderate to severe obstructive sleep apnea.
It is clear from even cursory review of the literature that there are a lot of people diagnosed with FM and CFS that have not been fully evaluated or treated.
When I was a Family Physician practicing Health Promotion the first question I asked new patients was, “How is your energy”? Most patients would tell me that their energy was low. For those who’s energy was low, my second question was, “How much sleep do you get”? I found it bizarre that the majority of these low energy patients would tell me, “I get enough sleep”. Most of my patients seemed to think that 6 or 7 hours of sleep per night was enough even if they were tired.
Then I would ask my patients, “What do you do when you feel cold”? The patient says, “I put on a sweater”. Then I ask, “What do you do when you feel hungry”? The patient says, “I eat”. I ask, “What do you do when you are thirsty”? The patient says, “I drink”. Finally, I ask, “What do you do when you feel tired”? The patient usually says, “I drink coffee”. No wonder there is such an epidemic of fatigue in our society. Fatigue is not due to a “caffeine deficiency”! A lot of people do not seem to understand that the most common cause of fatigue is lack of sleep and maybe they should try to get more.
Granted, a lot of people who are tired and sleep less than 7 hours per night are unable to sleep any longer even if they try. This is because they have developed a degree of “insomnia”.
The story goes that when you are a child you can usually sleep well but you do not want to go to bed. When you are a young adult you can often still sleep pretty well but you do not have the time. Then when you are retired you have the time, but you cannot sleep well anymore. This is because you have spent your whole life training yourself not to sleep when you are tired and now you are good at it I have been studying my patients with FM and CFS for many years, first as a holistically minded Family Doctor and then as a Sleep Disorders Physician. What became clear to me is that these conditions do not just suddenly start by themselves. There is usually a long history of either difficulty sleeping or voluntary sleep restriction due to life circumstances. Sleep is often not a priority. Because you are young and healthy you can push yourself and seem to get away with not enough sleep. You can function pretty well and may not even feel that bad because you are living on “adrenalin” that masks your fatigue. Maybe you get glimpses of how tired you are occasionally on a weekend when you slept in and you felt worse than if you had got up at your usual time. Then there is often a trigger such as an injury or an infection where you are forced to stop your high paced lifestyle. Without the ability to push yourself, the adrenalin wears off and you get a chance to see how tired you really are. You may blame your fatigue on the infection or the injury. However, after the infection clears up or the injury heals you are still tired. Alternatively, because you are maybe no longer a good sleeper or able to get enough sleep, the infection lingers, or the injury does not seem to heal (Refer to the section entitled “Why is Sleep Important”). In fact, if you have an injury, the pain makes your sleep worse and when your sleep gets worse, so does your pain.
Dr. Harvey Moldofsky published a study entitled “Musculoskeletal Symptoms and Non-REM Sleep Disturbance in Patients with Fibrositis Syndrome and Healthy Subjects" in Psychosomatic Medicine in 1976. Since then, it was discovered that there is no “itis” or inflammation in these patients. Instead, these patients have an “algia” or discomfort. Subsequently the name Fibrocytis was changed to Fibromyalgia.
Dr. Moldofsky discovered that patients with Fibrocytis had an abnormality in their deep, slow wave sleep called “alpha intrusion”. Alpha waves are a waking type brain wave that is not normally present in deep sleep. He associated this finding with “non-restorative sleep”. He found this same finding in patients suffering from CFS, Rheumatoid Arthritis and other chronic pain conditions.
Then, Dr. Moldofsky took a group of volunteers and monitored their sleep. Whenever they got into deep, slow wave sleep, he played an 80 db tone in their ear which prevented them from getting deep sleep. After 3 nights all the subjects developed symptoms of fibromyalgia including sore, tender muscles, fatigue, and reduced mood. On the first recovery night these patients got twice as much deep sleep. On next night they spent 50% more time than normal in REM sleep. By the next day, their symptoms had mostly resolved. Despite the disturbance to their sleep, these subjects did not have any more awakenings or less minutes of sleep than the control group.
Dr. Moldofsky was able to reproduce the symptoms of FM in only 3 nights of disturbed sleep. The subjects were able to recover naturally just by sleeping. Obviously, sleep is essential for health. For more information about why, go to the section entitled “The Importance of Sleep”.
Many clinicians try to differentiate between FM and CFS. Some Alternative Practitioners have come up with new names such as “Myalgic Encephalopathy” and “Adrenal Fatigue”. All of these conditions are really variations of basically the same thing. Sleep is when you heal and recover from day-to-day wear-and-tear or injury. If you don’t get enough quality and quantity of sleep, you cannot fully recover. As a result, you start to accumulate day-to-day wear-and-tear until you have symptoms of fatigue and soreness. Injuries have trouble healing. You may develop problems with concentration and memory. Without enough energy to cope, “molehills turn into mountains” more easily. It is easier to become stressed, anxious, or depressed.
People with FM and CFS have many strange symptoms that can distract a clinician into many areas of investigation and treatment. It is reasonable to rule out obvious medical and psychiatric disease with a basic medical history and physical exam with routine blood and urine testing. Then, a much more useful way of categorizing people with fatigue is to divide them into two groups. Those that get less than 8 hours of sleep and those that get more.
Those that sleep 8 – 9 hours might benefit from sleeping 9 – 10 hours. They might also benefit from optimizing their sleep quality with good Sleep Hygiene. However, more likely they have an underlying sleep disorder affecting their sleep quality. They would benefit from a consultation with a Sleep Disorders Physician and undergoing a Nocturnal Polysomnogram to more objectively evaluate their sleep. Those that are sleeping less than 8 hours per night would probably benefit from sleeping longer. Some of these people are unable to sleep longer because of a conditioned Insomnia. For more information about Insomnia, refer to the section entitled “What is Insomnia.” In order to train yourself to sleep longer whether or not you have insomnia, refer to the sections entitled “Insomnia Therapies”, “Resolving Insomnia Without Drugs”, “Sleep Hygiene”, “Relaxation Techniques”, “Biofeedback”, “Stress Management”, and “The Place for Psychotherapy”.
