All There is to Know About the Symptoms, Diagnostics, Treatments, and Comorbidities of Delayed Sleep Phase Syndrome
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Each of us has an internal circadian clock. In fact, the biological clock genes have been unchanged across several species and genus over the last million years. As a result, plant clock genes function the same way human clock genes function.
It is quite incredible to see how nature has conserved specific functions across multiple taxa. The expressions of these inheritable clock genes are highly diverse among the different organisms. In human beings and other higher animals, the clock genes determine the sleep-wake cycle and other factors of the circadian rhythm.
In the US, over 50 million people seek medical assistance for sleep disorders. Investigations estimate that there might be over 70 million people, who suffer from circadian rhythm disorders and other forms of sleep disorders. People see those with sleep disturbances and recurring bouts of chronic fatigue as lazy or weak. However, the case is rarely so.
People with sleeping disorders find it hard to experience restorative sleep or to fall asleep at socially acceptable hours. It causes accumulation of stress in their system and can lead to chronic sleepiness during the daytime. One such circadian sleep disorder is delayed sleep phase syndrome. People with DSPS find it difficult to fall asleep earlier than 12 am. Some of the people with chronic DSPS have sleep onset time at around 3 am or 4 am. As a result, their natural wake-up time is between 10 am, or 12 am.
Just because you have been feeling a little stressed these days, staying up late due to work and sleeping through your alarms up until 10 am, does not mean you have delayed sleep phase syndrome. For any circadian sleep-wake disorder, there must be a recurring history of at least three months. In most of the observed cases, the occurrence of DSPS began in the adolescent periods and continued into adulthood.
In many cases, researchers have seen the suppression of delayed sleep phases due to imposed social sleep-wake hours. As a result, children often miss out on 70 minutes to 90 minutes of sleep each night. The morning school hours keep them from completing their rest, and they suffer from daytime drowsiness, irritability, attention problems and other behavior problems.
There are several types of circadian rhythms among human beings. While most people practice monophasic sleep, people from Spain, Portugal, and countries of South East Asia practice biphasic sleep. The melatonin levels peak at night, resulting in sleepiness.There is another sleepy phase in the mid-afternoon which contributes to siesta or afternoon naps in the countries mentioned above. People usually depend on several external cues to conform to their natural sleep-wake cycles like sunlight, alarm clocks, television routines and mobile wake-up calls.
A group of people with seemingly “normal” circadian rhythms can exhibit vastly different sleep-wake cycles. While some people are more active during the mornings, others are more active during the evening or nighttime. The morning larks usually exhibit lower levels of melatonin early in the morning, and they complete their restorative sleep by 6 am or 7 am each day. The night owls are often self-diagnosed insomniacs with late bedtimes that can range between 1 am, and 4 am.
There might be biological causes driving these characters since people with DSPS are unable to alter their bedtime routines. People with normal circadian rhythms find it easy to adjust to new bedtimes and wake-up times, but those with any form of a circadian rhythm sleep-wake disorder find it utterly impossible to achieve restorative sleep during hours different from their internal clocks.
DSPS might sound a lot like jet lag to you, especially if you have recently traveled across the world to a foreign country. However, it is very different indeed. The drastic change in the day-night hours due to the time zone change causes jet lag, but delayed sleep phase does not depend upon external cues. Jet lag usually resolves quickly, quite unlike DSPS.
People with this sleep disorder have sleep onset insomnia, due to which they find it impossible to fall asleep at regular hours. These people are more likely to wake up tired due to incomplete restorative sleep, go through the entire day exhausted, but liven up during the evening. When night comes, they are again wide awake and unable to sleep despite the severe lack of sleep. It is an indefinite cycle that causes chronic sleep deprivation among the sufferers. Without medical attention, these people might find it difficult to achieve good quality sleep at modified hours.
You must realize that people with DSPS are not insomniacs either, although they tend to call themselves so. People with DSPS might find themselves awake at the wee hours of the night, but when they do fall asleep, they can experience restorative sleep as long as they stick to their internal biological clocks. Insomniacs find it difficult to fall asleep at any hour and do not suffer restorative sleep.
There are several stark differences between insomnia and DSPS since the treatments for them are entirely different from one another. Insomniacs can experience relief from their symptoms after treatment of underlying physical or mental disorders. The most common forms of therapy for insomniacs include behavioral therapy, psychotherapy and regulated administration of hypnotic medication. In case of DSPS, the diagnosis as well the treatment is more complicated. Investigators recently reported that over 10% of the self-diagnosed insomniacs in the US suffer from delayed sleep phase circadian disorder.
Over the years, experts have come to understand more about Attention Deficit Hyperactivity Disorder (ADHD) and its relationship with sleep. People with ADHD are often tired throughout the day. They are most likely to wake up feeling tired and stressed.
Although ADHD and sleep disorders have shared a long-standing relationship, researchers have only recently been able to explore the facets of the same due to the late onset of sleep disorders in ADHD individuals. Adults with ADHD, struggle with the following;
Several adults with ADHD report feeling a burst of energy as the sun goes down. Most of them endure drained off energy throughout the day, but they are re-energized as soon as they hit the hay. The incidence of sleep onset disorders usually begins among the ADHD individuals after the onset of puberty.
Currently, over 70% of the adults with ADHD report sleeping issues on a regular basis. Since over 80% of these cases indicate staying awake till about 4 am, it is understandable why they find it extremely difficult to wake up at socially acceptable times. They can sleep through alarms and angry mothers with ease. Several of these individuals report feeling groggy until noon.
In most of these cases, the night owls do not face a problem with their schedule. It is their friends, families, schools or employers, who become the source of their problems. ADHD and DSPS are ancient lovers and separating them is not any easier without behavior therapy, chronotherapy, medication, and psychotherapy.
Research shows intricate relationships between ADHD, depression, dementia and genetic abnormalities that tend to be inheritable. If you are currently suffering from DSPS, you must have already noticed that your internal clock is at least 2 hours behind the external clock. Experts often label this as “social jetlag” since the bodies and minds believe its midnight when its morning and the affected individuals appear to be tired and worn during morning meetings and morning classes.
Internal clocks are not always set for 9-5 work hours. People have their response system to external light and dark cues, which depend on the functions and products of their biological clock genes. Experts have observed that in most cases of DSPS, there is a complex correlation of causes including both internal and external stimulus.
Currently, the researchers believe that people with DSPS are unable to reset their sleep-wake periods as per external stimuli like light, darkness and noise. It can be because their biological clocks are not as sensitive to environmental cues. While it can be due to an aberrant increase or decrease in melatonin levels, it can also be due to continuous exposure to bright light right before bedtime.
Delayed sleep phase is not insomnia or the lack of proper quality sleep. It is a lesser than a typical sleeping pattern that occurs among teens, young adults and adults alike. Office workers often report feeling wide awake at night and sleepy in the early office hours. It can be due to lifestyle effects or due to internal mechanisms which can trigger DSPS.
The diagnosis of a complex disorder takes time and keen testing. Over the years, technology has advanced, and it has allowed the doctors to diagnose DSPS decisively among individuals.
Sleep Log. In multiple cases, doctors recommend the maintenance of a sleep log. It can be a diary or a journal where the patients keep a record of their daily sleep onset time (approximate time), waking up time and incidences of sleep disturbances if any. This diary should also include daytime naps, incidences of drowsiness, exact times of caffeine consumption and a food log. Keeping a sleep diary helps the experts understand the tendencies of the internal system of an individual and their responses to environmental stimuli. Including the regular medication also helps experts understand the way DSPS might find its way into an individual’s life.
Actigraphy. Actigraphy helps significantly in the diagnostic process. It is a non-invasive method of observing the sleep-wake cycles in a human subject. The actimetry sensor helps in monitoring the cycle in individuals. With the advancement of technology, the actigraphy has become a wearable gadget that resembles a watch. This small but mighty gadget can keep an eye on the sleep patterns and circadian rhythms of an individual.
Polysomnography. Polysomnography is the gold standard of sleep assessment in individuals. Experts recommend polysomnographs since it is a multi-parametric test that can monitor brainwaves, eye movements, muscle movements and several other related body functions. This test can also measure the rates of respiration and monitor the sleep stages accurately.
Melatonin levels. Biochemistry now allows the scientists to study the levels of melatonin at specific intervals in the system of an individual. The study of the increase and decrease in the melatonin levels can help the sleep experts understand precisely what your body needs to stimulate sound sleep at socially acceptable hours. There are real-time melatonin level assays available, but there are several constraints including the cost that limits their availability to ordinary people.
The diagnosis of DSPS is not as simple as many of us would like it to be. Although the overlapping results from some diagnostic procedures increase the accuracy, multiple doctors still rule out environmental factors as potential causes of DSPS. It makes it extremely necessary to log the exact hours of waking, eating, napping and sleeping, along with daytime drowsiness, unexpected feelings of overwhelming confusion and even frequency of exposure to bright light in your sleep log.
Sleep experts have been busy the last few years, trying to find a cure for delayed sleep onset in human beings. Several methods and medical compounds have failed to cure DSPS up until now, but the results have given experts further insight into the management of this circadian rhythm disorder.
Sleeping habit modification. Since DSPS usually begins during adolescence; kids with such symptoms need to do everything in their control to get as much restorative sleep as possible. Parents need to be more understanding, yet at the same time, they must keep their children from consuming caffeinated products.
Maintaining a calm, quiet and non-blue light bedroom can be conducive to timely rest. Avoiding sleeping medication without professional advice, drinking alcohol and addiction to nicotine can disrupt quality sleep in all ages. Do not exercise for about 5-6 hours before bedtime. Finish heavy workouts before evening. Keep your bedroom for sleeping only. Leave your mobile phones and iPads outside or keep them switched off inside your bedroom.
If possible, take a long warm shower before bed, drink some chamomile tea and try to hit the hay at the same time every day. It will help you entrain your circadian rhythm into following a more desirable sleep-wake cycle.
Chronotherapy. People undertaking chronotherapy often experience an advancement of their bedtimes and wake up times. Interestingly, it is quite impossible to shift people’s bedtimes earlier with chronotherapy, so the experts try to push their cycles further back till it entirely overlaps with the next day’s desired sleep-wake cycle. This method simple exploits the entrainable trait of our internal body clock. The process delays the bedtime of an individual by 3 hours at the maximum each day till they achieve desired sleep-wake cycle.
Chronotherapy allows youngsters and adults to adapt to socially acceptable resting schedules, without curtailing their sleep hours. The challenge comes with adhering to the new routine for an extended period as long as their social responsibility demands it. However, delaying the sleep onset time among DSPS patients can cause serious health issues. You should only try this under the care of a sleep expert or a doctor.
Bright light therapy. This involves a bright light box that can suppress melatonin secretion in the early hours of the morning. The increase in melatonin levels is responsible for sleep onset, and as we sleep, the levels of this neurohormone deplete in our system. Those who do not get to complete their sleep, have leftover melatonin from the previous night which makes them drowsy and muzzy next morning. This is what we see in people with DSPS most often.
Exposure to bright light in the mornings helps to lower the melatonin levels inside the body and reset the internal clock. The duration of exposure to the light needs to be between 30 minutes to 2.5 hours long, and the intensity should be around 10,000 lux. It is one way to tell the biological clocks that it is morning. You do not need to travel to a clinic every day for bright light therapy. You can now find several commercial and medically approved bright light boxes for regular use.
Dark therapy. This is the absolute opposite of bright light therapy. If the bright light in the mornings can stimulate awakeness, the avoidance of bright lights in the evenings can stimulate sleep. One can avoid bright lights in the evening by merely using blue light blocking goggles, checking their television time and cutting back their time on digital screens.
Children and adolescents of today are more likely to suffer from DSPS due to the frequent and constant use of digital screens that are the most prominent source of blue light in our day-to-day lives. You can experience an improvement in sleep onset time and sleep quality by avoiding the use of gadgets at least 3 to 4 hours before sleep. Several subjects have reported considerable improvement upon dark therapy.
When experts coupled dark therapy with light therapy, more than 75% of the times, the patients could conform to a 9 to 5 schedule for long periods of time without the recurrence of chronic delayed sleep phase.
Medications. Medications that can control DSPS are quite severe and can have significant side effects. Therefore, you should take somnolent only upon advice from an expert or a doctor. Melatonin and several other hypotonic compounds help in advancing the sleep onset time for people with DSPS. Medications usually work better with other forms of therapy like behavior or sleep habit improvement and chronotherapy.
Several methods can advance the sleep onset time for those with DSPS, but none of them can fully cure it unless the person has the motivation to stick to the new schedule. It is very common to find the individuals with DSPS to give up after a short while because it is too tiring or too demanding. You must remember that it is a property of your internal biological clocks, so you must keep at it to overcome the complications due to the DSPS you might be facing now.
When a primary disease occurs with another or multiple others, then all the secondary diseases are comorbid disorders. For example, obesity often causes related heart problems and circulatory problems. Then the latter diseases are the comorbid disorders that occur along with or as a cause of obesity.
Contrary to what many people believe, comorbidity can occur as a result of the primary disease or independently with the primary disease. In several instances of adolescents and adults with delayed sleep phase syndrome, experts have noticed the concurrent symptoms of anxiety, depression and side effects of medication that delay sleep. It is still debatable whether ADHD causes DSPS or DSPS contributes to ADHD symptoms.
Researchers have often seen seasonal affective disorders (SAD) and delayed sleep phase disorder occur together. SAD occurs in people, who usually reside in places that experience prolonged periods of darkness during the winter months. The lack of natural light and increased exposure to artificial lighting often leads to abnormal levels of melatonin that disrupts their 24-hour circadian rhythms. Due to several constraints, researchers have not yet been able to explore the comorbidity of these disorders, but it is quite definite that they influence one another.
Obesity is another comorbid condition that occurs with DSPS. People with delayed sleep are more likely to resort to binge eating or indulge in midnight snacking. The untimely nature of increased carbohydrate intake sends a boost of energy to the system. Excess calories contribute to more adipocyte formation in human beings. It not only disrupts the natural sleep cycle, but it also affects the onset of sleep. It is a leading cause of health concern in the first world countries like the US, where over 30% of the adult population is obese.
The lack of proper sleep and delayed sleep onset can lead to some behaviour problems in adults and youngsters alike. The instances of DSPS induced personality disorders that are more common among the adolescents and young adults. It can be due to social changes, peer pressure or due to surmounting pressure in school.
Several studies have also shown that DSPS affects children and adolescents more frequently than adults. Kids find it difficult to adjust with school routines as a result. They often face consternation for missing classes, being late or sleeping in since parents, teachers and even doctors deem them to be lazy. However, delayed sleep phase syndrome is a severe disorder that demands medical attention in all ages.
You must introduce several lifestyle changes to manage your delayed sleep-wake cycle.
Modification of sleep patterns is quite severe, and you must only perform that upon the strict supervision of an expert or a specialist. During the time of change, you might experience daytime drowsiness, sudden periods of confusion and slow response to external stimuli. Sleep experts suggest their patients to avoid driving long distances and handling heavy machinery during this period.
If you are late for school or work every day because you struggle with your alarms every morning, it is time to do a double check. Do you always go to bed late? Do you often find yourself stargazing into the late hours of the night? Is your tendency to fall asleep late older than 3 months? If the answer to these questions is a “yes,” then you need to consult a sleep expert or a medical professional. These are telltale signs of delayed sleep phase disorder. Due to the high instances of comorbidity, DSPS demands instant attention from experts.
Co-founder of Counting Sheep and Sleepaholic