Good night? Sleep and chronic pain
Dr Nicole Tang (Croucher Fellowship 2003) is a clinical psychologist studying the interaction between sleep and chronic pain. The findings of her research group at Warwick University are pointing the way towards new integrated treatments.
“Thoughts can have a direct impact on our emotion, behaviour and even physiology. The way how we think about sleep and its interaction with pain can influence the way we cope with pain and manage sleeplessness. Based on clinical experience, whilst some of our beliefs are healthy and useful, others are rigid and misinformed." explained Tang.
Tang started to work on insomnia as a doctoral student at Oxford University. As a Croucher postdoctoral fellow at King’s College London she moved on to study chronic pain. Many patients with chronic pain also have sleep problems, and the link between sleep and chronic pain is the focus of Tang's laboratory at Warwick University.
This balance between experimental and clinical psychology is critical to her work on insomnia and chronic pain. Without the experimental side to prove whether certain issues are causal or not, and the clinical aspect to yield data on sleep quality, researchers have no way to see the impact of various different factors on different patients. Tang aims to create a laboratory environment to actually measure the minutiae of sleep and pain, including sleep architecture, waveforms, micro-arousals, timings, causality, and more. This includes a great deal of input from patients, psychologists, physicians, clinicians, and statisticians, helping to form a basic understanding of what’s going on, which could then allow for a feasibility trial and, gradually, a clinical trial. A feasibility trial is essentially a dress rehearsal, demonstrating that a new therapy or treatment is replicable in local settings and within the National Health Service guidelines, based on its delivery of protocol, affordability, patient experience, and measurable outcomes.
While chronic pain and insomnia have different methodologies and treatments, the association between the two motivates Tang to collect more evidence in order to optimise the treatment. Tang advocates for a hybrid treatment not just to separate clinical diagnoses, but also to personalise treatment that addresses individual circumstances. The key to this is understanding the underlying psychological processes, such as the experimental side of her research, which includes the impact of pain on the sense of self. The psychological impact of pain also includes mental defeat, suicidality, and high-risk behaviour. “Many people get stuck between medical and psychological offices, going to a pain specialist first, then their psychologist for anxiety or depression, and their GP for sleep medication. Somehow in the midst of all this, they feel more unsupported than ever. Trained therapists, however, could see the whole person first and meld the medical and psychological aspects properly,” she remarks.
Tang hopes to break a stagnancy of treatment for chronic pain that has stood for more than twenty years. In contrast with group therapy, which is cost effective but not suitable for everyone, her proposed hybrid treatment is more individualised and requires more evidence-based components and a Tang’s emphasis on individualised treatment allows therapists to better understand the relationship between various symptoms, and at the same time provide deeper psychological support.
Chronic issues are at the top of the disease burden in primary care, because they drain the healthcare system over time, making her work even more of a priority. There is a real need to change the current treatment pathways to ensure chronic pain and insomnia are not addressed as isolated problems, and to view sleep as a good treatment entry point. “The impact of sleep on pain is bigger than pain on sleep. By providing pain patients with sleep treatment, we can improve their quality of life—their mood, physical activity, things that patients always ask for. But we need to change the culture of normal healthcare pathways, and show that this hybrid approach is more pragmatic and cost-effective,” Tang says. But it’s a slow process; Tang ran her first preliminary study in 2006, publishing the pilot’s results in 2012, and hopes to run a randomised feasibility trial in five or six years.
“Everyone engages in psychology every day; you move to new environments, observe different social dynamics of new groups of people, form ideas about people’s behaviour,” Tang notes. Following her early interest in psychology, she went on to study social sciences with a concentration in psychology at the University of Hong Kong and later, received her doctorate in Experimental Psychology at Oxford University. Though she wanted to be a clinical psychologist initially, her postdoctoral fellowships fostered a fascination with the use of research to really understand conditions before intervention, and to create more holistic and effective treatment. With this in mind, Tang furthered her clinical expertise alongside her research emphasis throughout her training.
Tang hopes that her work can be applied beyond clinical settings. Insomnia and other sleep disorders, or even occasional lack of sleep, often come with other conditions. “Most people have no clear idea about what to do to protect their sleep or regulate their patterns, or even the importance of quality sleep on their well-being,” she says. “Instead of attributing poor sleep to stress, exhaustion, or on call, we as a society should commit to changing our culture and make conscious decisions to protect our health,” Tang explains.
“Psychology is not a soft science or something to turn to only in case of crisis,” Tang says, “We need more young people to bridge this divide, to elevate the science and practice of psychology. I hope they believe in themselves and be explorative.Find creative scientific connections that could help improving public health.”
Dr Tang is a HPC registered Clinical and Health Psychologist and a Chartered Psychologist with the British Psychological Society. She studied Psychology in Hong Kong and obtained her doctoral degree in Experimental Psychology from the University of Oxford. Between 2004 and 2011, she was awarded 4 competitive fellowships (including a Croucher Postdoctoral Fellowship) to develop her research in world-leading pain research centres; the Institute of Psychiatry, King’s College London and the Arthritis Research UK Primary Care Centre at Keele University. She now directs the sleep and pain lab at the University of Warwick. Her research focuses on pain and insomnia.
To view Dr Tang’s Croucher profile, please click here.