Advanced Sleep Protocol by James Lake MD
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Integrative Protocol for Sleep Disturbance By James Lake, MD
Sleep concerns are a common problem in Western countries where a significant percentage of the population is affected by stress. Disturbances of nighttime sleep are associated with many emotional, mental and medical conditions, including substance abuse, and are commonly reported effects of many medications and some supplements. Severity of emotional trauma or mental stress is directly related to the probability of developing sleep disturbance.
When evaluating a client who complains of sleep disturbance it is important to assess and address all underlying medical or psychiatric causes. This involves a thorough medical history and review of all medications and supplements including doses and times of day they are taken. A common medical cause of sleep disturbance and daytime fatigue is hypoglycemia and every client with symptoms or chronic fatigue should be asked about their diet and whether sleep problems are related to food preferences or the timing of meals. Other medical concerns that cause sleep disruption include pain, sleep apnea, lung disorders such as asthma and COPD, and heart disease. Asking the client to keep a sleep diary can help clarify the pattern and severity of sleep disturbance including middle awakenings, early waking and naps. Conventional sleep studies using electroencephalography can help determine whether abnormal brain electrical activity is causing sleep disturbance.
The integrative approach to sleep disturbance
When advising a client who complains of sleep concerns, I always start out with reviewing dietary preferences. Simple dietary changes such as reducing caffeine and sugar consumption often improve sleep quality and reduce daytime fatigue. Next I introduce the concept of sleep hygiene. Good sleep hygiene consists of following a routine schedule for going to sleep and waking up, avoiding alcohol and large meals late at night, minimizing stressful activities and doing things to reduce stress such as meditating, practicing yoga or listening to soothing music before bedtime.
After telling a client about the benefits of sleep hygiene and the problems and side effects of sleep medications, my next step is to briefly comment on select natural supplements. Melatonin is often effective for moderately severe delayed sleep onset and is especially effective for circadian rhythm sleep reversals caused by jet lag or shift work. Early morning bright light exposure therapy is also effective related to a disturbance in the body’s normal circadian rhythms. Large placebo-controlled studies have shown that a standardized extract of valerian root supports sleep quality and can help individuals fall asleep and stay asleep. The amino acids L-tryptophan and 5-hydroxytryptophan are calming at certain doses and effective for situational sleep disturbance related to stress.
Finally, I encourage my clients to engage in a mindfulness or mind-body practice. The regular practice of meditation, mindfulness-based stress reduction (MBSR), guided imagery and progressive muscle relaxation often have beneficial effects on sleep quality and duration.
Moderately severe occasional sleep disturbance
Effective management of sleep disturbance and fatigue that are related to clearly identifiable stressors and unavoidable circumstances in the absence of complicating medical or psychiatric problems can often be achieved through simple strategies including improved sleep hygiene, regular exercise, the consistent practice of simple relaxation routines including guided imagery or progressive muscle relaxation, and use of melatonin, valerian extract and other supplements at appropriate times in the client’s sleep-wake cycle for the purpose of supporting the quality and duration of sleep.
Valerian is a widely used sleep support botanical. Standardized extracts of Valerian root at doses between 600 and 900 mg just before bedtime seldom cause residual morning grogginess. Placebo-controlled studies have shown that valerian extract is effective support for moderate to severe occasional sleep disturbance. It is important to advise clients using valerian root extract that the herbal should not be taken with a benzodiazepine or other sedative-hypnotic medications, or with alcohol as doing so could result in excessive sedation with potentially life-threatening consequences.
Early morning full-spectrum bright light exposure can significantly improve sleep quality and duration and reduce daytime somnolence especially when these problems are related to circadian rhythm disturbances caused by jet lag or shift work. An effective and safe integrative strategy for improved sleep and diminished daytime somnolence involves combining bright light exposure therapy in the early morning (i.e., relative to the client’s sleep schedule) and taking a sustained release form of melatonin before bedtime).
Severe Occasional Sleep Disturbance
Sleep disturbance is severe when it results in considerable distress, extreme fatigue, or symptoms of cognitive impairment that interfere with one’s capacity to function at work, in school, in a relationship, or in other day to day activities. Symptoms of severe occasional sleep disturbances include:
- Difficulty falling asleep almost every night without taking a sleep aid
- Experiencing frequent awakenings throughout the night
- Waking up early and being unable to return to sleep
- Recurring disturbing dreams or nightmares
- Frequent ‘automatic behaviors’ when sleeping such as sleep walking or involuntary leg movements
During the initial interview it is important to inquire about chronic work stress, relationship problems, medical illnesses that can manifest as chronic sleep problems such as heart disease, chronic pain, diabetes and obstructive sleep apnea, as well as substance abuse, and to find out about possible inappropriate uses of prescription medications that may interfere with normal sleep. Sleep disturbance is a common symptom of depressed mood, bipolar disorder, anxiety disorders and post-traumatic stress disorder, and it is important to inquire about these problems. If alcohol or other substance abuse is identified, it is important to refer the client to a recovery program.
In cases where sleep disturbance is associated with mood and stress, a reasonable integrative strategy involves use of the amino acid 5-HTP. 5-HTP should not be used adjunctively with SSRI medication due to the risk of elevating serotonin too high, resulting in serotonin syndrome.
Finally, encouraging clients to use good sleep hygiene, practice progressive muscle relaxation or guided imagery before bedtime, and to engage in a regular mindfulness practice often result in significant improvements in sleep quality and duration while also positively affecting mood.
The information and advice related above is based on my e-book ‘Alternative Treatments of Insomnia: Safe, Effective and Affordable Approaches and How to Use Them.’
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James Lake MD is a Board certified psychiatrist in private practice in Monterey, California. Dr. Lake has served as a clinical assistant professor in the department of psychiatry and behavioral medicine at Stanford, and is currently a visiting assistant professor of medicine at University of Arizona School of Medicine, Center for Integrative Medicine. He founded and chaired the American Psychiatric Association’s Caucus on Complementary, Alternative and Integrative Mental Health Care from 2004 through 2010, and is a founding member and former chair of the International Network of Integrative Mental Health. He is currently co-chair of the working group on integrative mental health in the Consortium on Academic Healthcare Centers in Integrative Medicine. Dr. Lake has published numerous peer-reviewed articles and contributes a regular column on integrative mental health care to Psychiatric Times. He serves on various editorial review boards including Alternative Therapies in Health and Medicine, Journal of Alternative and Complementary Medicine, Psychiatry and Psychology. Dr. Lake has authored several textbooks on integrative mental health and a series of ebooks titled “The Integrative Mental Health Solution”.
For more on Dr. Lake’s journal articles and presentations go to Progressivepsychiatry.com