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Old 09-04-2010, 08:27 AM
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Delayed Sleep Phase Disorder vs. Insomnia

Delayed sleep phase disorder and insomnia are two different disorders. Patients with delayed sleep phase disorder, or D.S.P.D., usually have difficulty falling asleep, but once they fall asleep they have no difficulty obtaining a full night’s sleep and typically sleep until late morning or early afternoon. Those with insomnia, on the other hand, may have difficulty falling asleep or staying asleep, wake too early or feel that sleep is not restorative. Most insomnia patients have a combination of these symptoms, such as difficulty falling asleep as well as staying asleep. Insomnia is also usually due to some specific cause, such as a medical or psychiatric disorder like depression.

Our bodies are biologically programmed, through circadian rhythms, to sleep at night and be alert during the day. In some people, these rhythms can shift, causing sleep and wake times to fall outside a desired schedule. In delayed sleep phase disorder, the sleep cycle is pushed later into the night, with a delayed natural morning wake time.

Many patients with delayed sleep phase disorder consider themselves “night owls.” It’s common for us to delay our sleep and wake times because of late-night parties and other social activities, but this does not mean we have the disorder. People with delayed sleep phase disorder are unable to return to a normal schedule, despite trying, and end up spending a prolonged time in bed awake before falling asleep. If you are able to fall asleep easily on resuming a normal bedtime after a few late nights, then you do not have delayed sleep phase disorder.

An opposite but similar condition, called advanced sleep phase disorder, is commonly seen in older adults. This disorder occurs when a patient falls asleep earlier than desired but awakens very early in the morning after getting a full night’s sleep. The patient, in this case, has great difficulty staying awake later into the night.

We commonly see delayed sleep phase disorder in young teenagers, whose circadian rhythm naturally shifts from a bedtime of 8 p.m. or 9 p.m. to as late as 11 p.m. or midnight during adolescence. Teenagers may need as much as 9 or 10 hours of sleep a night but often need to awaken early in the morning for school. As a result, they are often sleep-deprived and tired during the day. A current line of research suggests there should be later school start times for teenagers, with earlier school times reserved for younger children. Teenagers respond and do better in school when learning during biologically optimal times. Although delayed bedtimes are fairly normal in adolescents, treatment for D.S.P.D. should be sought if it is causing significant difficulties with morning awakening, excessive daytime sleepiness, irritability or attention and concentration problems and does not easily respond to an earlier bedtime.

There is often some confusion in the diagnosis of delayed sleep phase disorder, since the condition can easily look like a form of insomnia. For example, we often see patients in our practice who are told they have typical insomnia and do not fall asleep until 3 a.m., thereby obtaining only three to four hours of sleep per night. However, when asked how they sleep on the weekend or on vacations without any restrictions on wake time, they obtain seven or eight hours with no problem; for example, they may sleep from 3 a.m. until 11 a.m.

Understanding the difference between delayed sleep phase disorder and insomnia is important, as the treatments are very different. Insomnia disorders can be treated behaviorally, often in combination with hypnotics or other medications or treatment of the underlying medical or psychiatric disorder. Delayed sleep phase disorder usually requires juggling several different specific treatments; seeking out the help of a sleep specialist can prove very beneficial.

One option for delayed sleep phase disorder is chronotherapy. In this treatment, the patient delays the sleep period later and later every day by two to three hours until the bedtime and waking time eventually come fully around to the desired times. Chronotherapy can be an effective treatment for some, but it has its limitations when it comes to practicality, as it requires the patient to spend a few days sleeping during the day and being awake all night. The patient needs to limit all activities as well as light and noise during the protected sleep periods.

Another very effective option is bright light therapy, which is given in the morning for delayed sleep phase disorder. This requires the patient to sit in bright light for an hour at a time. Sunlight can be highly effective, though many choose to use an indoor light box for convenience, particularly on cloudy days or in the winter. It is advisable to seek the help of a sleep specialist, since use of bright light at the wrong time of day can actually worsen the problem.

Finally, melatonin, a natural hormone made by the body’s pineal gland, is also effective in treating circadian rhythm disorders, including delayed sleep phase disorder and jet lag. Melatonin is usually used in combination with behavioral and sometimes other pharmacological treatments. In cases of delayed sleep phase disorder that are difficult to resolve, we often have to use three or four different treatment options at the same time in order to help the patient. Though many people also use melatonin for insomnia, it is usually not very effective for that condition.

The pineal gland is inactive during the day, but when the sun goes down, it becomes active and begins to naturally produce melatonin. Melatonin is commonly sold in health food stores and pharmacies as an over-the-counter dietary aid (since it is naturally found in some foods) and is not currently regulated by the Food and Drug Administration. As a result, listed doses and ingredients may not be completely accurate.

Melatonin has documented side effects, including daytime sleepiness, headaches, confusion, dizziness, abdominal pain, sleepwalking and nightmares. It can also have a negative interaction with certain medications, including blood thinners, diabetes medicines, immunosuppressants and birth control pills.

We also advise that you seek the help of a sleep specialist when considering using melatonin, since taking the wrong dose of melatonin at the wrong time of day can adversely affect your circadian rhythms. Smaller doses (0.5 milligrams) are typically given earlier in the evening to gradually pull the circadian drive earlier, therefore allowing for earlier bed and wake times.

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