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Sleep Disorders

Chronotherapy & Delayed Sleep Phase Disorder

03/24/2009

Question:

I think I have delayed sleep phase disorder. I am interested in trying to adjust my sleep cycle by going to bed 2-3 hours later each night until I get to an 11pm to 8am sleep schedule. Some information I see says that I should only do this while working with a physician. What are the reasons? Why can`t I just try this myself over the next week? My current sleep schedule is that I fall asleep around 3am and wake up about 11am or later. It doesn`t seem to matter when I try to go to sleep. I am 36 years old. In high school, I never had any issue going to sleep or getting up in the morning (always at 6:30am). This continued through my freshman year of college. However, my sophomore year of college, I had a distinct change in that I could no longer wake up easily in the morning, but had no problem at night. My best work was done between 10p and 2am. Recently, the problem seems to have gotten worse. I start a new job soon, I am desperate to get on a "better" schedule. Thanks!

Answer:

It sounds like you have given significant thought and research to your problem. There is difference between a delayed sleep phase (going to bed, waking up late), which is what you have, and delayed sleep phase disorder (going to bed late and having to get up early resulting in inadequate sleep). As your work schedule is going to change, it’s reasonable to try and change your sleep schedule so your delayed sleep phase does not result in delayed sleep phase disorder.

The body’s circadian rhythms usually cycle over a 24 to 25 hour time period. These rhythms are reset daily to match a 24 hour day by factors such as exposure to daylight and social cues, for example when we eat our meals. The internal clock can be advanced (moved forward so you are sleepy earlier in the evening) or delayed (moved backwards so you are more awake late into the night) by changing the timing of light exposure and other social cues. However, the internal clock can only be adjusted by 1-2 hours in either direction per day with these maneuvers. When individuals try to alter their rhythms by more than this, they tend to feel poorly with fatigue, sleepiness and nausea (as seen with Jet Lag, for example). Furthermore, it often takes several days to fully adjust our circadian rhythms to a new schedule and thus going back and forth between schedules over the course of a few days can be difficult. This problem is often seen in persons who perform rotating shift work. They feel chronically fatigued and tend to suffer from a lack of adequate sleep. A delayed sleep phase disorder (DSPD) is usually diagnosed by a combination of history, sleep diaries and/or actigraphy, which measures your level of activity over a period of time, commonly over 1-3 weeks.

However, in addition to these criteria all other sleep, medical or psychiatric disorders must be ruled out first. Sleep-onset insomnia can look very similar to a delayed sleep phase disorder, as can depression or thyroid abnormalities. These disorders would have very different treatments.

Having said that, your history does suggest a delayed sleep phase and it’s reasonable to try and change it with your lifestyle about to change. Several different therapies for DSPD have been looked at and are usually best managed under the care of a physician with experience in these areas. Two examples of treatment in include light therapy and melatonin. Light therapy is commonly employed. Bright light (10,000 lux) for 30 minutes one hour prior to normal wake time can advance your internal clock and then can be used as maintenance as soon as you wake up. Melatonin has also been used to induce sleepiness earlier in DSPD.

Another technique that can work for some individuals with DSPD is to “sleep through the clock.” This requires a person to have no other daytime commitments and to adhere to a strict sleep schedule. The idea here is to delay the sleep schedule by 2 hours a day (gradually moving bedtime back through the day) until the individual reaches their desired bedtime, whereupon they maintain a regular sleep schedule at that time thereafter. This approach can be difficult and requires close supervision, usually by a Sleep Specialist, in addition to a very flexible and motivated patient. A physician would individualize the protocol for you after analyzing your history and determining that this is the best therapeutic option for you and if this should be used in conjunction with other therapies. If you wish to choose this approach, we generally recommend it be done under the guidance of a physician.

If you would like further information about DSPD, circadian rhythms, or sleep itself, I recommend the American Academy of Sleep Medicine website. In addition to information about sleep medicine, the website also contains a list of accredited Sleep Centers and may help you to locate one nearest you.

Best of luck in the new job!

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Response by:

Aneesa M Das, MD Aneesa M Das, MD
Assistant Clinical Professor of Pulmonary, Allergy, Critical Care & Sleep Medicine
College of Medicine
The Ohio State University