Delayed sleep phase syndrome

Delayed sleep phase syndrome also called delayed sleep phase disorder (DSPD), delayed sleep wake phase disorder or delayed sleep phase type, is a disorder in which a person’s sleep is delayed by two or more hours beyond the socially acceptable or conventional bedtime. This delay in falling asleep causes difficulty in waking up at the desired time. As an example, rather than falling asleep at 10:00 pm and waking at 6:30 am, an adolescent with delayed sleep phase disorder will fall asleep well after midnight and have great difficulty getting up in time for school.

When delayed sleep phase syndrome starts to interfere with ‘life’, by conflicting with daily routines such as work or school then it is called delayed sleep phase disorder (DSPD). When the disorder comes into conflict with daily routines, such as school or work, that requires waking up earlier than would otherwise be natural, the disorder could lead to sleep deprivation and other issues. Delayed sleep phase is responsible for 10% of all chronic insomnia cases.

Delayed sleep phase disorder (DSPD) is common among adolescents and further increases their susceptibility to chronic sleep restriction and associated detrimental outcomes, including increased risk of depression, drug and alcohol use, behavioral problems, and poor scholastic performance ¹.

People with delayed sleep phase disorder generally don’t have trouble getting good quality sleep once they do drift off. But staying up late often means not having time to log enough sleep before morning. Not surprisingly, daytime sleepiness can be a common problem, but that’s not all. Regularly skimping on sleep needs can make you less focused and productive, and it can lead to depression and other psychiatric problems. For children and teens, it can lead to behavior problems and poor performance in school.

Most children and adolescents with delayed sleep phase disorder describe themselves as “night owls” and say they function best or are most alert during the evening or night hours. If they were to keep a sleep log it would show short sleep periods during the school/work week (with few or no awakenings during the night) and lengthy sleep-ins (late morning to mid afternoon wake up times) on the weekend.

The cause of delayed sleep phase disorder is unknown and a sleep doctor will usually diagnose it by asking you to keep a sleep log and describe your symptoms. Sometimes, a sleep doctor will have you undergo a sleep study in a clinic to make sure you don’t have any other sleep disorders. Then, a sleep doctor is likely to recommend some of the following tricks to help you get your sleep back on track.

• Make gradual changes: To shift your circadian rhythm (internal body clock) so you can fall asleep when you need to, make gradual adjustments. Shift your bedtime schedule 15 minutes earlier each night until it’s where you want it to be.
• Use light to your advantage: The right lights can help coax your body clock toward your desired sleep schedule. Consider using bright light therapy for a half hour in the morning (or going outside to soak up some sunshine), and then keeping your house lights dim at night as you prepare for bed.
• Practice good sleep habits: The same healthy practices that can help anyone get better sleep can help people with delayed sleep phase disorder, too. Avoid caffeine and alcohol too close to bedtime, and log off of electronic screens for at least 30 minutes before turning in. Create a sleeping space that’s cool, quiet, and dark.
• Keep it up: As tempting as it can be to stay up late on the weekends and sleep in when you have the opportunity, it’s especially important to stick to a regular sleep and wake schedule when you struggle with delayed sleep phase disorder. Unfortunately, there’s no cure, so even once you’ve gotten back on track, you’ll still be susceptible to falling back into your old habits. So the more you can stick to a regular schedule, the better.
• Consult a sleep specialist to find out if taking melatonin, a hormone that helps regulate sleep and wake cycles, might help you get your much needed sleep at the right time.

How do circadian rhythm sleeping disorders work?

Delayed sleep phase syndrome is one of many circadian rhythm sleeping disorders, and is the most prevalent of all such disorders. It is the opposite of advanced sleep phase syndrome, in which people go to bed and wake up earlier than normal. People with delayed sleep phase generally go to bed in the early morning hours, from 1 am to 4 am, and wake up later in the morning, from 8 am to 11 am. Socially active people, and those considered ‘night owls’, who feel more awake or sharper during the evenings, are at a high rate of having or getting this disorder.

When delayed sleep phase is not the result of another sleeping disorder, people who have it will achieve sleep quality and duration equivalent to those with normal sleeping schedules. If the delayed sleep phase is not interfering with daily routines, or is in fact complimentary of the subject’s routine, it may be advised to maintain the routine, as the circadian rhythm disorder might not be harmful.

Who is most likely to be affected by delayed sleep phase syndrome?

Delayed sleep phase affects as many as 15% of teens and adults, a much higher rate than advanced sleep phase syndrome, and those with delayed sleep phase are generally younger than those with advanced sleep phase syndrome. It often develops in adolescence and continues into early adulthood, though it may also begin in adulthood. It affects both genders equally. Like advanced sleep phase syndrome, delayed sleep phase syndrome also has a genetic link, and people with a family history of delayed sleep phase syndrome are 3 times more likely to have it as those with no family history of the disorder.

Environmental conditions can lead to the development of delayed sleep phase syndrome (DSPS) and delayed sleep phase disorder (DSPD). A lack of morning sunlight exposure, and an overexposure to bright evening sunlight are likely to lead to a shift in the circadian rhythm towards a delayed sleep phase.

How does bright light therapy work?

Bright light therapy is also an accepted treatment that has shown some positive results with delayed sleep phase syndrome (DSPS) and delayed sleep phase disorder (DSPD). It involves exposure to bright light at early morning hours shortly after waking up, and avoidance of bright outdoor light during the evening hours. This has been demonstrated to readjust the circadian rhythms of individuals to more normal schedules.

Does melatonin work to treat delayed sleep phase syndrome or delayed sleep wake phase disorder?

At least one sleep study in 2010 concluded that “Melatonin is effective in advancing sleep-wake rhythm and endogenous melatonin rhythm in delayed sleep phase disorder.” If you believe you’re experiencing delayed sleep phase syndrome or delayed sleep phase disorder consulting a sleep doctor should still be a priority to determine proper treatment.

Melatonin supplements come in different forms such as chewable tablets, pills, and liquids.

There are two different types of melatonin supplements, natural and synthetic. While the natural form of melatonin may sound like a better option, some say that since this type of melatonin comes from the pineal gland of animals, there is a risk of viruses. The synthetic form is man-made and is made to have the same chemical structure as natural melatonin.

There are some studies that show that taking melatonin is safe when taken short-term and that adverse effects are minimal when taken long-term ².

It’s also important to note that while melatonin by its self may be safe, it could interfere with other medications and may not be safe to take for those with certain medical conditions.

Side effects of melatonin include:

• Daytime sleepiness
• Dizziness
• Headaches
• Nausea
• Irritability
• A “hangover-like” feeling the next day ³

Other melatonin side effects that have been reported include:

• Feelings of depression while taking melatonin
• Worsening of bleeding in those with bleeding disorders
• Increased blood pressure in those who are taking certain blood pressure medications
• May increase the risk for seizures in those with a seizure disorder

Melatonin safety for kids

There is not much evidence to determine the long-term safety of melatonin in children and adolescents ⁴. There are also no human studies done on the safety of melatonin in women that are pregnant or breastfeeding, so it’s best to avoid it altogether if you’re in these categories.

Is it safe to take melatonin daily?

There are no known dangers of taking melatonin daily. There is little-no data published on long term melatonin use ⁵.

If you decide that a supplement isn’t right for you, there are other ways to try and boost your melatonin production naturally. Some things you can try include eating a healthy diet, reducing blue light exposure 2-3 hours before bedtime, getting sunlight during the day, and avoiding the use of lights if you wake up during the night.

If you are considering adding a melatonin supplement to your routine, make sure you discuss it with your doctor first, especially if you have any medical conditions or are taking medication.

Delayed sleep phase syndrome causes

The exact cause of delayed sleep wake phase disorder is not completely known. However, approximately 7% to 16% of adolescents have delayed sleep wake phase disorder. Thus, it is a common disorder. Scientists think delayed sleep wake phase disorder may be an exaggerated reaction to the normal shift in the internal clock that is seen in many adolescents after puberty. It is important to understand that this is not a deliberate behavior. Delayed sleep wake phase disorder most commonly occurs during adolescence, but cases have been reported during childhood; it is rare for it to begin after early adulthood.

Like advanced sleep phase syndrome, delayed sleep phase syndrome also has a genetic link, and people with a family history of delayed sleep phase syndrome are 3 times more likely to have it as those with no family history of the disorder.

Environmental conditions can lead to the development of Delayed Sleep Phase Syndrome (DSPS) and Delayed Sleep Phase Disorder (DSPD). A lack of morning sunlight exposure, and an overexposure to bright evening sunlight are likely to lead to a shift in the circadian rhythm towards a delayed sleep phase.

Delayed sleep phase syndrome symptoms

Delayed sleep phase syndrome is a sleep disorder that occurs when a person’s circadian ryhthm (sleep/wake cycle) is delayed from the typical day/night cycle. People with delayed sleep phase have a natural tendency to go to bed later and wake up later than what is typically considered normal.

Symptoms of delayed sleep wake phase disorder include:

• Inability to fall asleep at the desired time. This usually presents as insomnia complaints. It may be heightened by the social pressures teenagers feel to stay up late (homework, internet or cell phone use).
• Inability to wake up at the desired time and excessive daytime sleepiness. Usually this is the most common complaint because it is more readily evident than the nighttime insomnia. Because of the delay in falling asleep and yet still needing to get up at the required time for work or school, children or adolescents with delayed sleep wake phase disorder often experience excessive daytime sleepiness as a result of not getting enough sleep, at least on weekdays.
• Generally no sleep problems if allowed to maintain their desired sleep/wake schedule. If uncomplicated by other sleep disorders, children and adolescents with delayed sleep wake phase disorder sleep well through the night with few or no awakenings once they fall asleep. They simply suffer from a shift in their internal clock or sleep-wake cycle. Children and adolescents with delayed sleep wake phase disorder often sleep well during vacations or school breaks when there is no pressure to wake at a certain time. Sleep maintenance is not an issue.
• Depression and behavior problems. Children and adolescents with delayed sleep wake phase disorder may experience depression and other psychiatric problems including behavioral problems as a result of daytime drowsiness and missing school. Daytime drowsiness can also lead to lowered academic performance from missed school days or tardiness and inattention.
• Dependency on caffeine, sedatives or alcohol may also be seen.

People who have a delayed sleep phase which interferes with their routine often compensate by napping during the day, or sleeping excessively on weekends to counterbalance the deprived sleep during the week. This can lead to temporary relief, but perpetuates the delayed phase cycle.

Circadian rhythm disorders are caused by the body’s internal clock not resetting and adapting to changes in sleeping patterns, or doing so slowly. In most individuals, going to bed at a time different than what is normal for them will result in the circadian rhythm adjusting and allowing them to fall asleep and wake up as desired. In those with delayed sleep phase, even when suffering through lack of sleep, the body maintains its inclination to go to bed at the usual time, making it difficult to fall asleep even when feeling physically tired. Likewise the body will tend to wake up at the same time, regardless of the amount of sleep, be it too little or too much.

In contrast to advanced sleep phase, which has minimal effects on work or school obligations, people with delayed sleep phase are more likely to have their sleeping disorder interfere with their necessary daily schedule, leading to chronic sleep deprivation. This can negatively affect school or work performance and social standing. People with Delayed Sleep Phase Syndrome (DSPS) and Delayed Sleep Phase Disorder (DSPD) may be labelled as lazy, unmotivated or undisciplined.

Delayed sleep phase syndrome diagnosis

Delayed sleep wake phase disorder is diagnosed based solely on a description of the symptoms and sleep logs. Sometimes a non-invasive wrist-watch-like device called an actigraph may be used to confirm rest-activity rhythms. An overnight sleep study (polysomnogram) may be recommended to rule out the presence of any other sleep disorders. Sophisticated tests of melatonin or core temperature rhythms are generally reserved for research purposes.

Delayed sleep phase syndrome treatment

If delayed sleep phase is interfering with your daily schedule, it is important to take steps to minimize its effects. Nearly 50% of all reported subjects with delayed sleep phase syndrome also suffer with depression. While there is no easy cure for delayed sleep phase syndrome, and although delayed sleep phase syndrome has shown high levels of resistance to many treatment methods, consulting a sleep doctor should be considered.

The most common method of treatment is the gradual scaling back of sleeping times, until they achieve the desired time frame. The schedule would then be rigidly implemented. While this can be effective, maintaining the new routine is imperative, as it often resets completely if the individual diverts from the new habit even once with a late night.

Treatment for delayed sleep wake phase disorder involves the following:

• Good sleep habits. Children and adolescents with delayed sleep wake phase disorder need to do everything they can to develop and maintain good sleep habits and a consistent sleep schedule. Habits should include going to bed and waking up at the same times including on weekends and vacations; avoiding caffeinated products (coffees, teas, colas, some non-cola pops, energy drinks, chocolates, and some medications [Excedrin®]); avoiding other stimulants and products that can disrupt sleep (alcohol, sleeping pills, nicotine); maintaining a cool, quiet and comfortable bedroom; and avoiding activities before bedtime that are stimulating (computer games, smart phone, television use).
• Shifting the bedtime schedule. Treatment for delayed sleep wake phase disorder can involve one of two methods: advancing or delaying the internal clock.
  • Advancing the internal clock. This method simply moves the bedtime a bit earlier on each successive night until the desired bedtime is reached. For example, setting the bedtime at midnight on one night, 11:45 p.m. on the next night, 11:30 on the following night and so on.
  • Delaying the internal clock. This method moves the bedtime sequentially 1 to 3 or more hours later on successive nights until the desired bedtime is reached. This requires several days free from social activities and may be best attempted during a long school break or vacation period. The thinking behind this strategy is that it is much easier for the body to adjust to a later bedtime than an earlier one.
• Staying motivated to stick with the schedule. It is especially important not to lose sight of the goals during holidays and weekends. Adhering to strict bed and wake times keeps the body’s internal clock under control but does not “cure” the tendency toward a delayed sleep-wake phase. Once the desired bedtime is reached, your child or adolescent must stay motivated and stick with going to bed at the desired bedtime on a nightly basis in order to reset the internal clock. Only after several months of sticking to the schedule can there be some flexibility allowed on special occasions.
• Bright light therapy. Some physicians recommend bright light therapy, which requires the purchase of special light box. Exposing your child to bright light for approximately half an hour in the morning helps to reset the body’s internal clock. Reduced exposure to bright light in the evening also helps. Your sleep doctor will be able to suggest commercially available light boxes.
• Medications. Melatonin or other natural sleep-inducing drugs are another option some physicians may try.

References

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