Using routine as a therapeutic strategy

By Catherine Darley, ND

Having minimal routine and “going with the flow,” seems to have a certain popular cache nowadays. But creating structure in day-to-day life helps make the circadian rhythm more robust. As more individuals struggle with proper rest and energy, integrative practitioners can use routines to improve sleep quality in our patients.

In the human body, the primary time cue, which synchronizes the body clock, is the first light a person is exposed to in the morning. However, there are other cues, called zeitgebers, that help the body identify time of day. These secondary zeitgebers include meals, exercise, and social interactions.

Timothy Monk, PhD, DSc, director of the Human Chronobiology Research Program at the Western Psychiatric Hospital at the University of Pittsburgh Medical Center, and colleagues developed the Social Rhythm Metric (SRM), which records daily activities such as meals, exercise, work, and social interactions. Data is typically collected for a week or more and scores are assigned based on the timing of each activity. If the timing of an activity that occurs at least three times a week is within 45 minutes of the average or habitual time, it is considered a “hit” for daily routine. The total number of hits divided by the total number of activities occurring at least three times a week gives the SRM score. A higher SRM score was found to relate to better sleep, whereas lower scores correlated with higher reports of depressive symptoms.

In the last several years, there has been a growing awareness of the effect of circadian rhythms on human health. Along with this, there’s been a resurgence of interest in, and research using, the SRM. Regardless of age, the amount of regularity in daily social rhythms correlate with health. A three-year longitudinal study of college students found that regular social rhythms predicted positive mental health the following year. The reverse was also true, with emotional wellness predicting greater lifestyle regularity. In addition, for elderly patients living in a retirement community setting, better sleep was found in those people with the greatest regularity.

People with cyclothymia and bipolar II disorder have less lifestyle regularity than people without mental illness. Low social regularity has been found to be predictive of the first episode of bipolar disorder in those adolescents who are already at risk.

Having also observed with my patients that difficulty creating routine is associated with difficulty sleeping, I regularly use the SRM. However, recording the SRM is labor-intensive, and it is easy to get a sense of rhythmicity in a clinical interview, so instead I tend to use it to develop a treatment plan rather than assessment.

After discussing with a patient the ways lifestyle regularity can improve sleep, we use the SRM to design a rhythmic lifestyle. Typically, we will schedule a target time for each meal, out of bed, first contact with another person, morning beverage, start main activity whether it be work or other,  first time outside, take an afternoon nap, watch TV, other evening activity, exercise, return home for the last time, and bedtime. For those people who are primarily home, we plan designated time for activities outside of the home. We also discuss their social connections, and make sure there is a regular, predictable, time each day that they are interacting with others.

Take Dave, a 65-year-old male patient. Dave has been retired for about over two years, after working the same job with a regular daily work schedule for many years. He lives alone. Dave has insomnia for the first time, starting about three months into retirement. During the clinical interview, he reports getting up to start his day anytime between 5:30 a.m., (the time he previously got up for work), and 9 a.m., depending on what he had scheduled that day. He enjoys the chance to linger in bed after so many years of getting up early. His activity times are widely variable, and often he ends up just going to do his errands whenever he gets bored at home. He does not participate in any regularly scheduled events. He is overall happy being retired, though he doesn’t have enough to fill his days. He reports low stress.

This phenomenon of insomnia beginning in retirement is a surprising one that has presented regularly in my practice. This seems to be a risky time for some people, as they go from a situation where their job has imposed structure. Similar risks can be seen during periods of unemployment, being home for medical reasons, or becoming a stay-at-home parent.

For Dave, we established regular wake times and bedtimes, a little later than during his work time since that felt like a luxury for him. Because he lives alone, a key part of the plan was regular social interaction, starting with a 15-minute walk each morning to his preferred coffee shop. This provides not only the regularity, but the dose of sunlight to help synchronize his body clock and social interaction.

Immediately afterwards is the main activity of his day, whether it is a scheduled class or appointment, or simply errands. As part of creating his new lifestyle, he considered adult learning classes on topics he hadn’t had time for before. He also joined a senior hiking club. Afternoons are when he is at home doing maintenance projects and relaxing. In the evening, he may or may not have other social events. Wind-down time starts an hour before bed, which he sets his phone alarm for a reminder. At that time, he turns the lights low, turns down the thermostat, and listens to music or a book on tape.

I suggest patients aim to begin every activity within 30 minutes of the target time each day. At a follow-up appointment, people usually report a reduction in anxiety and improvement in sleep with regularizing their routine. They also express surprise that something this simple could make such a difference. What Dave reported is that his sleep normalized, which he especially attributed to the regular wake time and something to look forward to in the dependable routine of starting his day with a short walk and seeing folks at the coffee shop. He also said that though he had felt happy to be retired, in retrospect his mood was low as he hadn’t had enough interesting activity to fill his days.

For some patients in my clinic, there is still a struggle to establish a routine. It is something they must actively, intentionally work at. Once you’ve established a plan, get reminders in place such as using the smartphone alarm for prompts, or grouping activities such as lunch is followed by exercise. You can also link activities with social connection. Sometimes one person in the household easily maintains a routine, and your patient can intentionally follow the timing cues of their housemate.

This is an arena where I expect our understanding will only grow in the next decades and we will discover more mental and physical health arenas that are impacted by lifestyle regularity. As holistic practitioners, we can embrace this treatment strategy now, as a way patients can design a healthful life. It’s time to discard going with the flow, and embrace the fact that regularity promotes health.

References

Alloy, L., Boland, E., Ng, T., Whitehouse, W., Abramson, and L.. (2015) Low social rhythm regularity predicts first onset of bipolar spectrum disorders among at risk individuals with reward hypersensitivity. Journal of Abnormal Psychology. .  Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/26595474

Cai, D., Zhu, M., Lin, M., Zhang, X., and Margraf, J. (2017) The bidirectional relationship between positive mental health and social rhythm in college students: a three-year longitudinal study. Frontiers in Psychology.  Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/28713318

Monk, T., Flaherty, J., Frank, E., Hoskinson, K., and Kupfer, D. (1990) The Social Rhythm Metric. An instrument to quantify the daily rhythms of life. The Journal of Nervous and Mental Disease Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/2299336

Shen, G., Alloy, L., Abramson, L., and Sylvia, L. (2008) Social rhythm regularity and the onset of affective episodes in bipolar spectrum individuals. Bipolar Disorder. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/18452448

Zisberg, A., Gur-Yaish, N., and Shochat, T. (2010) Contribution of routine to sleep quality in community elderly. Sleep. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/20394320

About the Author

Catherine Darley, ND is the founder of The Institute of Naturopathic Sleep Medicine in Seattle, Washington. The Institute’s mission is to provide patient care and public education about sleep health, and research on natural treatments for sleep disorders. Darley writes reviews of sleep health topics regularly for professional naturopathic journals.