By Allison Siebern, Ph.D.
A middle-aged patient who we will call Katy came to the Stanford Sleep Center's Insomnia & Behavioral Sleep Medicine Program seeking help for her sleep. Katy reported that she had tried everything to be able to sleep at what she called a "typical time." She presented with concerns about being unable to get to sleep until the a.m. hours, oversleeping in the morning, and feeling groggy and un-refreshed upon awakening. She would get into bed around 11 p.m. (some nights earlier) and not fall asleep until around 3-4 a.m. Katy would set an alarm for 7 a.m. and try to force herself awake but would turn the alarm off in her sleep and would sleep until 11 a.m. or noon. She was frustrated that so much of her 24 hours was spent "trying" to sleep, and she reported she had to fix her sleep situation as soon as possible because a family member recently became ill requiring her to drive the family member to early morning doctor's appointments.
The sleep issue was discussed with her primary care physician, and the offered treatment was sleep medication. She was reluctant about taking it, but tried for several nights with little to no effect and eventually discontinued it. Her primary care physician also offered her the advice that she just needed to relax at night, which led to her feeling that the problem was just dismissed and not taken seriously. She had read about sleep hygiene on the Internet. Based on what she had read she had eliminated caffeine, replaced her mattress with a new one, darkened her room, and ensured a comfortable room temperature during her intended sleep time. She had also started general psychotherapy several months prior to her first visit at the Stanford Sleep Center to try and help her sleep and had completed 12 sessions, which included elements of sleep hygiene and relaxation techniques. Katy reported none of these helped her sleep.
The patient also reported a long history of this sleep issue dating back to adolescence when she would oversleep and miss classes in high school and would sleep into the afternoon on weekends. In college she scheduled afternoon classes as much as possible since she knew she would oversleep and not make it to the morning classes. She reported times when her sleep would drift later and later until eventually she would periodically have a night that she would stay up all night. When asked about a family history of any sleep issues she indicated that her maternal grandmother had had a similar pattern of sleep. After completing an initial evaluation with the patient and gathering sufficient sleep history it was identified that the patient had delayed sleep phase syndrome (DSPS). Time was then spent educating the patient about DSPS and she became tearful as she heard the explanation. She stated it matched what she had been struggling with for so many years and she was so grateful to finally have a name for it.
The brain has an internal master clock that has a daily cycle that is approximately 24 hours. In delayed sleep phase the master clock oscillates longer than a 24-hour period leading to later sleep onset and later wake time. DSPS is a circadian rhythm sleep disorder that occurs when the timing is delayed several hours relative to the external 24-hour clock. Those with DSPS struggle with getting to sleep at a "typical bedtime" because their internal clock is sending high alerting signals at that time indicating they should be alert and awake. If the person waits to go to sleep much later (usually some hours after midnight) getting to sleep is faster as the alerting signals are quieting down.
The person will also report difficulty waking up at their desired morning wake time because their internal clock is not yet producing (nor sending) strong alerting signals. In addition, there remains sleep debt to be slept off due to falling asleep at a later hour. There is variation in the length of the oscillation period and thus how strong the delay is, with a mild to significant impact on sleep. Unless there is disruption in occupation, social, or other domains (or aspects) in life due to the timing of sleep a person, it is not considered to be DSPS, but the person is said to have a delayed circadian chronotype. (This basically means they are more of a night owl but it does not impact the above domains of their life.) In the general population the prevalence of DSPS is unknown but among adolescents and young adults it is approximately 10 percent. Most commonly, DSPS emerges during adolescence, but it can even occur during early childhood. Recent research indicates there is a genetic link with circadian chronotype, so it was not surprising that Katy could identify someone in her family that experienced a similar sleep pattern.
Recommendations were discussed with Katy that were tailored to where her current sleep time was and how to move the circadian timing to her goal of waking earlier. It involved an intensive two weeks of shifting her sleep time around the clock slowly enough to be effective, which is called sleep phase chronotherapy. (It is a common misconception that by staying awake all night that one can reset their sleep clock, which more often than not subsequently disrupts the sleep pattern more.) Additional treatment components for Katy included properly timed light exposure, limiting light exposure in the hours before her anticipated bedtime, and observing the activities she was doing two hours prior to her bedtime and being careful not to get over-activated, thus suppressing her sense of sleepiness. She found the above recommendations most helpful for her, although recommendations for delayed sleep phase can vary across patients.
Time was also spent examining beliefs and expectations around sleep given Katy's long history of frustrating experiences. It is worth noting that she reported feeling guilt and shame around the timing of her sleep, which started when she was a teenager. She received messages from her family about being lazy for missing classes and for sleeping later on the weekends. This was reinforced during her working years when she would be consistently late when working a 9 a.m. to 5 p.m. job. (She eventually found employment that allowed for a later shift.)
The patient had four treatment sessions over a six-week period. At the last session the patient expressed relief in finally having answers to what she was experiencing and direction in how to manage it more effectively. She recognized that the treatment did not change her genetics nor her biology, so this issue would always remain in the background. Nevertheless, she learned about the treatment recommendations and factors that were effective for her to help regulate her pattern. These could be put into place if her sleep pattern started to shift later and later.
The details of the above patient have been altered to preserve privacy and confidentiality. This case illustrates that sleep hygiene guidelines and non-specific treatment (general psychotherapy) are not typically effective in treating sleep disorders. It also illustrates that sometimes other sleep disorders such as a circadian rhythm disorder can masquerade as insomnia, but the treatment plans vary and so it is important to have an evaluation done by a sleep expert.
To find a certified behavioral sleep medicine provider please go to: http://www.absm.org/BSMSpecialists.aspx
Allison Siebern, Ph.D. is a clinical assistant professor at the Stanford Center for Sleep Sciences and Medicine. This Center is the birthplace of sleep medicine and includes research, clinical, and educational programs that have advanced the field and improved patient care for decades. To learn more, visit us at: http://sleep.stanford.edu/
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