Delayed Sleep-Phase Disorder
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
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Cited by (21)
Delayed sleep phase syndrome and bipolar disorder: Pathogenesis and available common biomarkers
2018, Sleep Medicine ReviewsDepression and Hypersomnia: A Complex Association
2017, Sleep Medicine ClinicsCitation 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 ClinicsCitation 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 ReviewsCitation 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].
The delayed sleep-wake disorder: A personal experience of management combining light and melatonin
2015, Medecine du SommeilEvaluation of novel school-based interventions for adolescent sleep problems: Does parental involvement and bright light improve outcomes?
2015, Sleep HealthCitation 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.