Elsevier

Sleep Medicine Clinics

Volume 4, Issue 2, June 2009, Pages 229-239
Sleep Medicine Clinics

Delayed Sleep-Phase Disorder

https://doi.org/10.1016/j.jsmc.2009.01.006Get rights and content

Delayed sleep-phase disorder (DSPD) can range from mild to severe and affects not only an individual's sleep but also daytime functioning. A comprehensive assessment is necessary to reliably estimate the degree of circadian-phase delay and thus determine the most effective treatment (morning bright light or chronotherapy). For phase advancing the circadian rhythms and sleep-wake cycle, the recommendation is a schedule of incremental advances of wake-up time and morning bright light as well as low-dose early-evening melatonin administration. It is also important to treat any psychophysiological insomnia with cognitive/behavior therapy. For the more extremely delayed DSPD individual, chronotherapy involving delays of scheduled sleep periods in increments of 2 hours is recommended. Following either type of therapy, maintenance of consistent wake times, exposure to morning light, changes in lifestyle, and improvement of attitudes about morning times are also recommended to help prevent relapse.

Section snippets

Prevalence and etiology

Estimated prevalence rates for DSPD have ranged from 0.2% to 10% of the population.1, 2, 4, 5, 6 The apparently large range of these prevalence estimates may be due to variation of the severity criteria for the delayed sleep period. Less severe cases of DSPD (eg, 2 am to 10 am sleep period) are likely to be more prevalent than the more extreme delayed cases (eg, 5 am to 2 pm sleep period). A recent study found the habitual sleep-onset times of patients diagnosed with DSPD varied between about

Clinical diagnosis and assessment

It is suggested that virtually all DSPD patients score as extreme evening types although not all evening types report the distress required for a diagnosis of DSPD. Perhaps many of these nondistressed extreme evening types have adapted their lifestyles to accommodate delayed circadian rhythms.34

Diagnosis of a delayed sleep-wake schedule is made from a 1- to 2-week sleep-wake diary and actigraphy if available.35 Sleep parameters documented on the diaries include bedtime and lights-out time,

Therapies for delayed sleep-phase disorder

Treatments that change the circadian rhythm phase or timing, such as morning bright light, exogenous melatonin, and chronotherapy, have been effective in treating delayed circadian rhythm sleep disorders.

Because of the very strong tendency for those with DSPD to phase delay, treatments to phase advance take longer and are more difficult than phase delaying the same degree of phase change or number of hours to achieve the target sleep period. For example, in a DSPD case with an unconstrained

Morning bright-light therapy

Bright light is an effective intervention for phase advancing the circadian rhythm. The timing and duration of the light stimulus as well as the brightness and wavelength of light affect the magnitude of phase shift. The human phase response curve to light suggests a phase advance of the circadian rhythm is achieved when the light stimulus is presented immediately after the time at which core body temperature reaches CTmin, its endogenous minimum.42, 43, 44, 45

Measuring CTmin or dim-light

Lifestyle considerations

Before commencing light therapy, the clients' sleep and wake-up time goals need to be determined realistically, taking into account motivation to change their current sleep-wake schedule, difficulties with compliance to the treatment, and the amount of phase change required. If clients have significant early-morning obligations, then the motivation to comply with therapy instructions should be sufficient. On the other hand, simply the desire to achieve a more “normal” wake-up time without any

Application of morning bright-light therapy

After estimating the CTmin from the sleep-wake diaries, a schedule for light exposure can be established, taking into account the client's practical obligations. Ideally, this schedule involves slowly advancing morning light exposure by 30 minutes each morning or alternate mornings until the target wake-up time is reached. Light exposure for at least 1 to 2 hours commencing about 1hour after the estimated CTmin is recommended. However, if the client's sleep-wake pattern is quite variable and

Melatonin

Exogenous melatonin administration is also capable of shifting the circadian rhythm to a more desired time.61 Phase response curves for melatonin administration show that melatonin in the early evening phase advances the rhythm. The maximum advance occurs when multiple 3-mg doses are administered approximately 5 hours before the original DLMO or smaller doses (0.5 mg) are administered approximately 3 hours before the estimated DLMO.62, 63, 64 For good sleepers, DLMO occurs approximately 2 hours

Chronotherapy

Chronotherapy involves progressively delaying bedtime each day until the desired bedtime for the individual has been reached.2, 79 The treatment shifts the individual's light-dark cycle as well as sleep period, and exposes the individual to light before the scheduled bedtime in the phase-delay portion of the phase-response curve, consequently facilitating the delay of the circadian rhythm.80 Contributing to the phase delay is the endogenous tendency in most individuals for phase delaying

Behavioral strategies

The conditioned activation response associated with sleep-onset insomnia can be ameliorated with the application of behavior therapy, such as stimulus control therapy.82, 83 For clients undergoing morning bright-light therapy, the time at which they are able to initiate sleep may advance slower than their bedtime if they advance their bedtime at the same pace as their wake-up time. This can produce lengthened sleep latencies and lead to the development or worsening of psychophysiologic

Summary

DSPD can range from mild to severe and affects not only an individual's sleep but also daytime functioning. A comprehensive assessment is necessary to reliably estimate the degree of circadian phase delay and thus determine the most effective treatment (morning bright light or chronotherapy). For phase advancing the circadian rhythms and sleep-wake cycle, the recommendation is a schedule of incremental advances of wake-up time and morning bright light as well as low-dose early-evening melatonin

References (85)

  • T. Roth et al.

    Effects of ramelteon on patient-reported sleep latency in older adults with chronic insomnia

    Sleep Med

    (2006)
  • R.R. Bootzin et al.

    Behavioral treatments for insomnia

  • E.D. Weitzman et al.

    Delayed sleep phase syndrome: a biological rhythm disorder

    Sleep Res

    (1979)
  • E.D. Weitzman et al.

    Delayed sleep phase syndrome: a chronobiological disorder with sleep-onset insomnia

    Arch Gen Psychiatry

    (1981)
  • American Academy of Sleep Medicine

    International classification of sleep disorders

  • L.C. Lack

    Delayed sleep and sleep loss in university students

    J Am Coll Health

    (1986)
  • R.P. Pelayo et al.

    Prevalence of delayed sleep phase syndrome among adolescents

    J Sleep Res

    (1988)
  • H. Schrader et al.

    The prevalence of delayed and advanced sleep phase syndromes

    J Sleep Res

    (1993)
  • K. Mundey et al.

    Phase-dependent treatment of delayed sleep phase syndrome with melatonin

    Sleep

    (2005)
  • G. Kerkhof et al.

    Circadian phase estimation of chronic insomniacs relates to their sleep characteristics

    Arch Physiol Biochem

    (1999)
  • J.E. Nagtegaal et al.

    Delayed sleep phase syndrome: a placebo-controlled cross-over study on the effects of melatonin administered five hours before the individual dim light melatonin onset

    J Sleep Res

    (1998)
  • D.A. Oren et al.

    Abnormal circadian rhythms of plasma melatonin and body temperature in the delayed sleep phase syndrome

    J Neurol Neurosurg Psychiatr

    (1995)
  • S. Ozaki et al.

    Prolonged interval from body temperature nadir to sleep offset in patients with delayed sleep phase syndrome

    Sleep

    (1996)
  • N.E. Rosenthal et al.

    Phase-shifting effects of bright morning light as treatment for delayed sleep phase syndrome

    Sleep

    (1990)
  • K. Shibui et al.

    Melatonin rhythms in delayed sleep phase syndrome

    J Biol Rhythms

    (1999)
  • D.R. Wagner et al.

    Entrained sleep and temperature rhythms in delayed sleep phase syndrome

    Sleep Res

    (1986)
  • A. Rodenbeck et al.

    Altered circadian melatonin secretion patterns in relation to sleep in patients with chronic sleep-wake rhythm disorders

    J Pineal Res

    (1998)
  • K. Shibu et al.

    Melatonin, cortisol and thyroid-stimulating hormone rhythms are delayed in patients with delayed sleep phase syndrome

    Sleep Biol Rhythms

    (2003)
  • T. Watanabe et al.

    Sleep and circadian rhythm disturbances in patients with delayed sleep phase syndrome

    Sleep

    (2003)
  • S.H. Strogatz et al.

    Circadian wake maintenance zones and insomnia in man

    Sleep Res

    (1985)
  • M. Morris et al.

    Sleep-onset insomniacs have delayed temperature rhythms

    Sleep

    (1990)
  • S.S. Campbell et al.

    Delayed sleep phase disorder in temporal isolation

    Sleep

    (2007)
  • S.N. Archer et al.

    A length polymorphism in the circadian clock gene Per3 is linked to delayed sleep phase syndrome and extreme diurnal preference

    Sleep

    (2003)
  • J.A. Horne et al.

    A self-assessment questionnaire to determine morningness-eveningness in human circadian rhythms

    Int J Chronobiol

    (1976)
  • M. Dworak et al.

    Impact of singular excessive computer game and television exposure on sleep patterns and memory performance of school-aged children

    Pediatrics

    (2007)
  • S. Higuchi et al.

    Effects of playing a computer game using a bright display on presleep physiological variables, sleep latency, slow wave sleep and REM sleep

    J Sleep Res

    (2005)
  • S. Li et al.

    The impact of media use on sleep patterns and sleep disorders among school-aged children in China

    Sleep

    (2007)
  • N. Suganuma et al.

    Using electronic media before sleep can curtail sleep time and result in self-perceived insufficient sleep

    Sleep Biol Rhythms

    (2007)
  • J. Van den Bulck

    Adolescent use of mobile phones for calling and for sending text messages after lights out: results from a prospective cohort study with a one-year follow-up

    Sleep

    (2007)
  • C.-M. Yang et al.

    A single dose of melatonin prevents the phase delay associated with delayed weekend sleep pattern

    Sleep

    (2001)
  • A. Taylor et al.

    Sleeping-in on the weekend delays circadian phase and increases sleepiness the following week

    Sleep Biol Rhythms

    (2008)
  • M. Wittmann et al.

    Social jetlag: misalignment of biological and social time

    Chronobiol Int

    (2006)
  • Cited by (21)

    • Depression and Hypersomnia: A Complex Association

      2017, Sleep Medicine Clinics
      Citation Excerpt :

      Some studies found that circadian rhythm disruption is a major feature in BD, even in drug-naive patients and independently of mood status,75 but with more frequent biological alterations in depressed than in euthymic patients. Delayed sleep phase syndrome (DSPS) is characterized by delayed habitual sleep-wake timing, usually greater than 2 hours, relative to conventional or socially acceptable timing.76 Affected individuals complain of difficulty falling asleep and arising at the required times, and frequently experience daytime hypersomnolence, especially in the first hours of the day.

    • Diagnosis, Cause, and Treatment Approaches for Delayed Sleep-Wake Phase Disorder

      2016, Sleep Medicine Clinics
      Citation Excerpt :

      Sleep logs or diaries allow patients to track their habitual sleep and wake times. The logs document several sleep parameters, such as when lights are turned out, when the patient gets into bed, how long it takes for the patient to fall asleep (sleep onset latency [SOL]), time spent awake after sleep onset (wake after sleep onset [WASO]), and wake time in the morning.24 In addition, logs can also include areas to document when caffeine, alcohol, sleep aids, or other medications are ingested in order to gain a more comprehensive understanding of factors influencing the patient’s sleep-wake timing.

    • The etiology of delayed sleep phase disorder

      2016, Sleep Medicine Reviews
      Citation Excerpt :

      It has been reported that 83% of CRSD are diagnosed as DSPD and it is the most commonly reported CRSD in clinics [12]. While prevalence of DSPD is poorly documented in empirical literature, depending on the diagnostic sample, it is estimated to range from 0.2% to 10% [9] or 0.5–16% [10]. Two recent DSPD prevalence studies reveal 3.3% out of a sample of 10,220 Norwegian high school students presented with DSPD diagnosis [35] while 8.4% out of a sample of 1285 had delayed sleep timing [36].

    • Evaluation of novel school-based interventions for adolescent sleep problems: Does parental involvement and bright light improve outcomes?

      2015, Sleep Health
      Citation Excerpt :

      Bright light therapy (BLT) is a common intervention used to regularize the sleep patterns of adolescents with delayed sleep timing.6-8,27 Incremental advances of wake-up time with immediate exposure to BL advances delayed circadian rhythms, thereby improving the timing of sleep patterns (ie, individuals fall asleep and wake up earlier).28-31 Considering students are mostly unwilling to spend time outside immediately after waking, an alternative novel source of BL (eg, portable light devices) could better enable students to “re-time” their sleep patterns.

    View all citing articles on Scopus
    View full text