A lot of people with inflammatory bowel disease (IBD) have trouble sleeping. By some estimates, roughly 75% of people with IBD experience sleep disturbances such as trouble falling asleep, trouble staying asleep, and poor overall sleep quality. Meanwhile, surveys of IBD patients have found that poor sleep tends to be the top contributor to quality-of-life issues.
The fact that so many people with IBD experience problems sleeping is bad news for a number of reasons. For one thing, a lot seems to go wrong with the human mind and body when sleep is inadequate; sleep disorders such as insomnia are strongly linked to an increased risk for a range of mental and physical health conditions, including depression and Alzheimer’s disease. But secondly, and maybe more importantly, researchers have found that poor sleep may worsen pain, fatigue, and other symptoms among people with inflammatory diseases like IBD.
While the relationship between poor sleep and IBD is something experts are still working out, they’ve already found evidence that the two conditions may have a bidirectional relationship, meaning they contribute to one another in unhelpful ways. According to the authors of a 2020 study in the journal Crohn’s & Colitis 360, people with IBD who sleep poorly may slip into “a cycle wherein sleep disturbance and IBD worsen and maintain one another, deteriorating quality of life and worsening overall disease activity and inflammation.” Another 2020 study, this one in the journal Inflammatory Bowel Disease, found that poor sleep was associated with greater inflammation and greater overall disease activity in people with IBD.
“In the clinic, I see a lot of IBD patients who wake up during the night due to symptoms,” says Dr. Faten Aberra, a gastroenterologist and associate professor of medicine at the Hospital of the University of Pennsylvania. But that’s only one way in which sleep and IBD may be interrelated. Depression is common among people with IBD, and it’s strongly linked to insomnia. Plus, some IBD medications can cause sleep disturbances. Determining how best to help an IBD patient manage their sleep problems depends in part on these and other underlying drivers.
The good news is that medical science is getting better at recognizing and treating the sorts of sleep issues that afflict people with IBD. Here, experts discuss the relationship between these two medical conditions, as well as how best to manage IBD-related sleep disturbances.
The connections between IBD and sleep
Sleep has a profound effect on the immune system. Researchers have found that levels of several cytokines—which are proteins that orchestrate the immune system’s inflammatory processes—tend to shift in predictable ways after a bad night’s sleep. In simple terms, the immune system often reacts to poor sleep as though it had encountered some kind of physical threat; it ramps up its defenses, including its levels of inflammation-stoking cytokines.
“We discovered some time ago that sleep loss produces a marked activation of inflammation at the cellular level,” says Dr. Michael Irwin, a professor of psychiatry and biobehavioral sciences at the David Geffen School of Medicine at UCLA. Sleep disturbances also shift the regulation of genes that play a role in immune functioning, he says. “We know that in people who have underlying autoinflammatory diseases such as rheumatoid arthritis, inflammation and pain go higher when they’re deprived of sleep,” he says. Research has found similar effects among people with IBD. Poor sleep is associated with an increased risk for flares among people with both ulcerative colitis and Crohn’s disease. And in people whose IBD is not well controlled, poor sleep seems to make symptoms worse.
While a night of poor sleep seems to heighten the severity of IBD, it’s also true that IBD interferes with sleep. “Inflammation is a biological signal that impairs depth of sleep,” Irwin says. “So you can get into this spiral of sleep disturbances and inflammation contributing to each other.”
Meanwhile, some mental or physical health problems that often co-occur with IBD can also contribute to sleep problems. For example, psychological disorders seem to be common causes of IBD-related sleep disturbances. “When we look at the things that people say are most impactful for their sleep, it’s not just the usual suspects—so not just bowel movements at night or abdominal pain,” says Dr. Jessica Salwen-Deremer, a psychologist and sleep specialist at Dartmouth Health who works with IBD patients. “It’s more likely to be a general feeling of unwellness, or feeling anxiety about bowel movements.”
In support of this, researchers have found that people with inactive IBD are almost as likely as those with active IBD to experience sleep problems. They attribute this in part to the elevated rates of mental-health disorders among IBD patients. “The heightened frequency of depression and anxiety is one explanation for the sleep problems we see,” says Dr. David Sachar, an IBD specialist and professor of medicine at the Mount Sinai School of Medicine in New York City. By some estimates, roughly 1 in 5 people with IBD has an anxiety disorder, and the incidence of depression among people with IBD is only slightly lower. A much higher percentage of IBD patients experience symptoms of anxiety and depression, and both of these mental-health problems tend to cause sleep disturbances.
Finally, Sachar says that IBD medications can mess with a person’s slumber. “People with IBD are often on steroids, and those can interfere greatly with sleep,” he says. Other medical conditions, including sleep apnea, are also major causes of sleep disturbances.
It’s easy to see why experts so often describe the relationship between IBD and sleep issues as complex. There’s a lot of crosstalk between the two conditions, and they may make each other worse. The good news is that by improving one or both sides of the sleep-IBD equation, you may find some relief from both. “You can target sleep and improve inflammation and pain,” Irwin says. “And the potency and efficacy of the sleep treatments we have is really remarkable.”
Addressing the problem
When you consider all the ways sleep and IBD interact, determining how best to remedy the situation can be tricky. Switching up your medications won’t help if your sleep issues are caused by sleep apnea or depression. Likewise, going to a sleep specialist for insomnia treatment won’t do you much good if you’re up at night due to your medications or uncontrolled IBD symptoms.
Determining the source (or sources) of your sleeping problems can involve some trial and error, but it’s best to start by talking with your IBD care provider. They’re used to hearing about sleep disturbances from their patients, and they can help you narrow down the likely causes and best remedies. That’s true even if your sleep problems aren’t directly caused by your IBD. For example, Aberra says that when her patients mention they’re having problems sleeping, she often recommends depression screening because she knows this is a common underlying issue and a cause of insomnia.
Sachar adds that, in his experience, people with IBD often have a good idea about what’s causing their sleeping problems. “They tend to know if it’s due to psychic effects, medication effects, or because of symptoms like having to get up and go to the bathroom,” he says. Don’t be afraid to tell your care team what you think is going on. A change in medications, or the addition of new meds to treat uncontrolled symptoms, could help you sleep more soundly, he says.
On the other hand, experts say that sleeping pills may not be the best solution. For one thing, these medications may not mix well with the drugs you’re taking to manage your IBD symptoms. There are also non-drug sleep remedies that may provide more durable relief from insomnia and all its related harms.
Arguably the most efficacious and evidence-backed sleep treatment is cognitive behavioral therapy for insomnia, or CBT-I. Some early research has found that CBT-I not only helps people sleep better, but may reduce IBD-related issues such as chronic pain, depression, and inflammation. “In our initial pilot trial among people with mild to moderate IBD, we saw some really awesome sleep outcomes,” says Salwen-Deremer. “People had quite significant reductions in the time it took to fall asleep and time awake during the night, and also increases in the duration of sleep.” People also reported reductions in disease activity, she says.
What is CBT-I? Salwen-Deremer says it’s a multicomponent treatment that includes education in proper sleep hygiene and stimulus control. (This is stuff most of us have heard about, like sticking with a consistent sleep-wake schedule, and avoiding caffeine, exercise, or other stimulating activities in the evening or before bed.)
But there’s a lot more to CBT-I than that. “It also involves sleep restriction, which is not something most people have experience with,” she says. In a nutshell, sleep restriction entails temporarily cutting down the time you spend in bed each night in order to deepen your sleep and improve your “sleep efficiency,” which is the proportion of your time in bed that you actually spend asleep. Salwen-Deremer says CBTI also involves relaxation training, as well as cognitive therapy. “This is where we examine how your thoughts may set you up for arousal in bed, and how to dispute those thoughts and create new balanced thought patterns that support sleep,” she explains.
While CBT-I may be effective for some forms of IBD-related insomnia, it’s not appropriate for all patients. For example, if you’re in the midst of a bad flare, sleep restriction isn’t a good idea, she says. Also, CBT-I also won’t do you as much good if your sleep problems are caused by sleep apnea or your IBD medications.
If you and your care provider determine that CBT-I may be helpful, she says it’s best done with the help of a trained professional. Digital resources or apps—Salwen-Deremer mentions Insomnia Coach and Sleepio as two evidence-backed options—are also helpful if you want to give CBT-I a try.
Read More: How to Best Treat Underserved IBD Patients
A complicated puzzle
The relationship between sleep and inflammatory bowel disease is complex.
There’s a lot of evidence that the two are interrelated, but researchers are still sorting out precisely how they play together—and how treating one may help relieve the other.
While more work is needed, experts are beginning to nail down the most effective remedies. Already, they’ve found that changing up your medications, addressing underlying psychological and medical issues (such as depression or sleep apnea), and improving your sleep with the help of therapies like CBT-I may all be useful. The bottom line is that if you have IBD and you’re not sleeping well, you don’t have to live with it. There are solutions.
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Contributor: Markham Heid