The sleep and dream specialist at the University of Arizona’s Center for Integrative Medicine provides an overview of IMA-I.
In 1990, I was given an opportunity to establish a sleep center within an alternative medical program at Canyon Ranch Health Resort in Tucson, Ariz. Andrew Weil, MD, had been instrumental in shaping this program and subsequently founding and directing the University of Arizona Center for Integrative Medicine, where I have served as the sleep and dream specialist since 2000. This overview of integrative medicine approaches to insomnia (IMA-I) is based on my experiences in these settings as well as my extensive clinical practice in behavioral sleep medicine.
Conventional medicine approaches to insomnia (CMA-I) fall short primarily because they encourage medicalization—a misconstrued notion of sleep as an essentially biomedical phenomenon.1 This posture encourages overreliance on sedative-hypnotics (the most common treatment for insomnia). And it likely discourages patients from availing themselves of more effective cognitive behavioral therapy for insomnia (CBT-I). Not surprisingly, the National Health Interview Survey analysis found that over 1.6 million US adults use complementary and alternative medicine (CAM) to treat insomnia or trouble sleeping, often without informing their physicians.2
As its name implies, integrative medicine is not an alternative to conventional medicine; it is an essential augmentation of it.3 Bringing together the best of evidence-based conventional medicine and CAM significantly expands both our understanding of and treatment options for insomnia. More specifically, an integrative medicine approach to insomnia demedicalizes sleep by 1) restoring our regard for the sleeper; 2) significantly expanding the range of effective interventions; and 3) reframing insomnia and sleep health as lifestyle issues.
Restoring Regard for the Sleeper
CMA-I has taught us much about the biomedical view of sleep, but it has all but forgotten the sleeper. CBT-I has strived to balance this medicalized view of sleep with a focus on cognition and behavior, but has been criticized for being too formulaic. In concert with integrative medicine’s concern for the critical role of the mind in health and illness,3 IMA-I encourages renewed regard for the personal, subjective experience of the sleeper. It embraces but also significantly expands the purview of CBT-I to include a meaningful consideration of dreams and spirituality.
The best antidote to medicalization is personalization. Sir William Osler reminded us that “it is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” It is arrogant to dismiss the phenomenological experiences of our patients. Let’s remember that scientific definitions of sleep are artificial parameters that frequently fail to coalesce with reports of subjective experiences. What has long been called sleep state misperception, for example, may well be sleep state perception. Our willingness to intentionally integrate objective data with subjective experience can help us triangulate a sharper scientific as well as a more personally meaningful picture of sleep.
Personalization begins by complementing standard insomnia evaluation procedures with an invitation to patients to tell their personal “sleep stories.” Integrative medicine emphasizes the importance of the doctor-patient partnership in healing.3 Our willingness to respectfully attend to and empathize with our patients’ sleep stories conveys an important sense of regard for their subjective experiences, countering the common tendency to treat the chart.
Integrative medicine also emphasizes the critical role of endogenous healing3—the acknowledgement of an individual’s natural inclination to heal. In my experience, helping a patient to feel heard, regarded, and understood not only increases disclosure, but also promotes self-efficacy and improves treatment adherence.
I routinely ask insomnia patients about their beliefs and experiences regarding dreams. Obviously, dreaming is the most evident and personally meaningful conscious experience of sleep. How much of WASO (wake after sleep onset) might actually be WADO (wake after dream onset)? Disregarding dreams in an insomnia consult is like disregarding the taste of food in a nutritional consult. At a minimum, I believe we should affirm dreaming as an essential component of sleep and even normalize occasional bad dreams and nightmares. Ideally, we should also explore the meaning patients attribute to their dreams.
As evidenced in the global ubiquity of bedtime prayers for safety and protection through the night, nonscientific views of sleep have traditionally been framed in spiritual terms. Integrative medicine suggests that scientific and spiritual takes on sleep are not mutually exclusive. In fact, given that the vast majority of Americans have religious beliefs, considering and incorporating these into treatment could enhance standard CBT-I. I have found it very useful, for example, to address sleep effort in terms of patients’ spiritual beliefs. The elusive process of letting go required for healthy sleep onset can be reframed and addressed as a spiritual practice or an act of faith.4
Utilizing Effective CAM Interventions
Valerian root has been used as a medicinal herb since at least the time of ancient Greece and Rome.
Integrative medicine substantially expands the range of evidence-based interventions available for treating insomnia in terms of sleep aids, relaxation practices, and alternative medical systems. Utilizing these interventions can help address overreliance on prescription and over-the-counter sleep medications as well as growing concerns about polypharmacy.
A detailed review of soporific botanicals and nutraceuticals is beyond the scope of this overview. It should be noted, however, that a growing body of evidence supports the use of a number of alternatives such as valerian root, lemon balm, l-theanine, kava, and jasmine, to name a few.5 Many of these alternatives have been used for centuries around the globe and have much better safety profiles than conventional hypnotics.
Soporific botanicals and nutraceuticals also can be useful in weaning patients from conventional sleep medications. I encourage patients to think of these as sleep appetizers that are intended to remind one of the taste of and hunger for sleep. They are not to be confused with the main course of natural sleep. I also advise my patients to complement taking something to sleep with the intention of letting go of something to sleep,6 that is, managing factors that fuel their hyperarousal.
A wide range of relaxation practices is known to be useful in the treatment of insomnia.7 In recent years, practices that have long been staples of integrative medicine, such as hatha yoga, mindfulness meditation, and breathing exercises, are finding acceptance in more mainstream medicine.
Breathing exercises, most of which are derived from ancient Ayurvedic pranayama practices, are particularly promising. Weil has long referred to breathing as the “master key to health.” Because respiration is the only physiological process that can be entirely under conscious or unconscious control, he sees it as a critical link between body and mind.8 Given the recent concern about respiratory correlates of insomnia,9 it would be interesting to investigate the potential benefits of pranayama.
Alternative medical systems refer to comprehensive, stand-alone models of healthcare such as traditional Chinese medicine (TCM), homeopathy, and Ayurveda. Although it is challenging to translate these perspectives into conventional medical terms, they call our attention to three arenas that might help advance our understanding and treatment of insomnia. These systems do not segregate body and mind, but address patients as whole integrated beings. They also strongly emphasize typology, classifying individuals in terms of biopsychological health predispositions. And lastly, they recognize human circadian rhythms as being inextricably tied to nature’s clock. I believe there is much of value we can learn from these perspectives.
Reframing Insomnia in Terms of Lifestyle
Over recent years, chronic inflammation has emerged as a ubiquitous substrate of a broad range of medical and mental health disorders, including insomnia.5 From its inception, integrative medicine has emphasized lifestyle in managing chronic inflammation.10 Lifestyle factors in insomnia have also long been recognized and commonly find their way into treatment as a list of sleep hygiene recommendations. As necessary as sleep hygiene may be, it has been found to be insufficient as a stand-alone intervention.11
Rubin Naiman, PhD
Integrative medicine encourages a systematic approach to lifestyle issues, sometimes referred to as “lifestyle medicine,” which includes specific attention to nutrition, exercise, and stress management.3 It also emphasizes heightened sensitivity to environmental factors in general and sleep health. In addition to conventional concern with ambient temperature and light, IMA-I calls attention to subtle environmental toxins such as chemicals in mattresses and bedding, indoor air pollution, and electromagnetic fields.5
Lifestyle medicine is not simply about managing illness. It is ultimately about experiencing the richness of life. It’s about passion, productivity, and peace. And it’s about enjoying sleep and dreams. We need to help patients rediscover the incomparable personal pleasures of sleep. I believe one of the most crucial steps in healing insomnia is learning to fall back in love with sleep.12
Rubin Naiman, PhD, is the sleep and dream specialist at the University of Arizona Center for Integrative Medicine. The Center for Integrative Medicine offers a number of local and distance learning training options for medical, mental health, and other allied health professionals. These include residency programs, a 2-year fellowship training, certificate programs, and a broad range of courses in integrative medicine. For additional information, visit www.integrativemedicine.arizona.edu.
References
1. Moloney ME. Up all night: The medicalization of sleeplessness. University of North Carolina, Chapel Hill, 2009. https://cdr.lib.unc.edu/indexablecontent/uuid:92bb6e87-dc33-4247-93e4-0f5af701a13d
2. Pearson NJ, Johnson LL, Nahin RL. Insomnia, trouble sleeping, and complementary and alternative medicine: analysis of the 2002 National Health Interview Survey data. Arch Intern Med. 2006;166:1775-1782.
3. Rakel D, Weil A. Philosophy of integrative medicine. In: Rakel D, ed. Integrative Medicine. 3rd ed. Philadelphia: Elsevier; 2012.
4. Naiman R. The Yoga of Sleep: Sacred and Scientific Practices to Heal Sleeplessness. Boulder, Colo: Sounds True; 2010.
5. Naiman R. Insomnia. In: Rakel D, ed. Integrative Medicine. 3rd ed. Philadelphia: Elsevier; 2012.
6. Naiman R. Healing Night: the Science and Spirit of Sleeping, Dreaming and Awakening. Minneapolis: Syren Books; 2006.
7. Morin CM, Hauri PJ, Espie CA, Spielman AJ, Buysse DJ, Bootzin RR. Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine review. Sleep. 1999;22:1134-1156.
8. Weil AT. Breathing: The Master Key to Self Healing. audio CD. Boulder, Colo: Sounds True; 2000.
9. Krakow B, Ulibarri V, Romero E, McIver N. A two-year prospective study on the frequency and co-occurrence of insomnia and sleep-disordered breathing symptoms in a primary care population. Sleep Med. 2013;14:814-823.
10. Rakel D, ed. Integrative Medicine. 3rd ed. Philadelphia: Elsevier; 2012.
11. Morin CM, Bootzin RR, Buysse DJ, et al. Psychological and behavioral treatment of insomnia: update of the recent evidence (1998-2004). Sleep. 2006;29:1398-1414.
12. Naiman R. Falling in love with sleep. Insights at the Edge. Sounds True, 2011. http://bit.ly/1PgTkG0
