A clinical approach to circadian rhythm sleep disorders

Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
Sleep Medicine (Impact Factor: 3.15). 09/2007; 8(6):566-77. DOI: 10.1016/j.sleep.2006.11.017
Source: PubMed


Circadian rhythm sleep disorders are characterized by complaints of insomnia and excessive sleepiness that are primarily due to alterations in the internal circadian timing system or a misalignment between the timing of sleep and the 24-h social and physical environment. In addition to physiological and environmental factors, maladaptive behaviors often play an important role in the development of many of the circadian rhythm sleep disorders. This review will focus on the clinical approach to the diagnosis and management of the various circadian rhythm sleep disorders, including delayed sleep phase disorder, advanced sleep phase disorder, non-entrained type, irregular sleep-wake rhythm, shift work sleep disorder and jet lag disorder. Diagnostic tools such as sleep diaries and wrist activity monitoring are often useful in confirming the diagnosis. Because behavioral and environmental factors often are involved in the development of these conditions, a multimodal approach is usually necessary. Interventions include sleep hygiene education, timed exposure to bright light as well as avoidance of bright light at the wrong time of the day and pharmacologic approaches, such as melatonin. However, it should be noted that the use of melatonin is not an FDA-approved indication for the treatment of circadian rhythm sleep disorders.

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Available from: Phyllis C Zee, Feb 04, 2014
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    • "Light as a therapeutic intervention for circadian-based sleep and medical disorders ( " phototherapy " ) is most commonly prescribed to occur before normal wake time or after normal bed time (Morgenthaler et al., 2007). While highly efficacious in theory, this type of therapy has poor effectiveness because compliance is low and, when compliance is adhered to, the therapy leads to chronic sleep deprivation (Bjorvatn and Pallesen, 2009; Barion and Zee, 2007). Our demonstration of effective light treatment during sleep without gross interference of sleep opens new avenues of therapy because the light treatment is nonintrusive and requires no change in behavior from the recipient. "
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    ABSTRACT: The human circadian timing system is most sensitive to the phase-shifting effects of light during the biological nighttime, a time at which humans are most typically asleep. The overlap of sleep with peak sensitivity to the phase-shifting effects of light minimizes the effectiveness of using light as a countermeasure to circadian misalignment in humans. Most current light exposure treatments for such misalignment are mostly ineffective due to poor compliance and secondary changes that cause sleep deprivation. Using a 16-day, parallel group design, we examined whether a novel sequence of light flashes delivered during sleep could evoke phase changes in the circadian system without disrupting sleep. Healthy volunteers participated in a 2-week circadian stabilization protocol followed by a 2-night laboratory stay. During the laboratory session, they were exposed during sleep to either darkness (n = 7) or a sequence of 2-msec light flashes given every 30 sec (n = 6) from hours 2 to 3 after habitual bedtime. Changes in circadian timing (phase) and micro- and macroarchitecture of sleep were assessed. Subjects exposed to the flash sequence during sleep exhibited a delay in the timing of their circadian salivary melatonin rhythm compared with the control dark condition (p < 0.05). Confirmation that the flashes penetrated the eyelids is presented by the occurrence of an evoked response in the EEG. Despite the robust effect on circadian timing, there were no large changes in either the amount or spectral content of sleep (p values > 0.30) during the flash stimulus. Exposing sleeping individuals to 0.24 sec of light spread over an hour shifted the timing of the circadian clock and did so without major alterations to sleep itself. While a greater number of matched subjects and more research will be necessary to ascertain whether these light flashes affect sleep, our data suggest that this type of passive phototherapy might be developed as a useful treatment for circadian misalignment in humans.
    Journal of Biological Rhythms 09/2014; 29(5). DOI:10.1177/0748730414546532 · 2.77 Impact Factor
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    • "Because of this delay the adolescent is often not able to initiate sleep at their desired time [10]. This mismatch between the desired sleep time and the circadian rhythm commonly leads to secondary insomnia-type symptoms, such as increased sleep onset latency, and in particular increased cognitive arousal [10] [13] [14]. Cognitive treatments have been applied to samples of adolescents with DSPD (e.g., cognitive restructuring, mindfulness-based stress reduction) [10] [14], however, the field is limited in its understanding of the cognitive aetiological factors associated with DSPD in adolescents [15]. "
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    ABSTRACT: Catastrophising is a repetitive cognitive process related to sleep disturbance in adult insomnia patients. More recently catastrophising has been associated with increased sleep disturbances in community samples of children and adolescents, with this association mediated by anxiety and depression. However, there currently is no evidence of these processes outside of community samples; impeding our ability to draw clinical conclusions. Knowledge on such dysfunctional cognitive processes in adolescents experiencing sleep disturbance would be clinically beneficial in aetiology and intervention. Our research examined the link between catastrophising, anxiety, depression and sleep latency in a sample of sleep-disordered adolescents. We also explored specific catastrophising themes which may impact the sleep latency of these adolescents. Forty adolescents (age=15.1±1.5years, 53% boys) diagnosed with delayed sleep phase disorder completed a 7-day sleep diary, along with measures of anxiety and depression and a catastrophising interview with a trained sleep therapist. Several catastrophisation themes were generated, the most common concerning interpersonal and performance aspects of school. Bootstrapping analyses showed depression did not mediate the relationship between catastrophising and sleep; however, an indirect relationship was found between catastrophising, anticipatory anxiety, and sleep latency. These findings have implications for the role of dysfunctional thinking in prolonging sleep onset for adolescents and providing a clinical framework for health professionals when assessing and treating adolescents with delayed sleep timing.
    Sleep Medicine 10/2013; 15(1). DOI:10.1016/j.sleep.2013.09.014 · 3.15 Impact Factor
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    • "ASPT patients show extremely advanced involuntary timing of sleep and wake, DSPT patients show significantly delayed sleep onset and wake times, and FRT patients have sleep times that occur with ~1-h delay each day and are not able to adapt to the external 24-h day. CRSDs are attributed etiologically to malfunction and/or maladaptation of the circadian clock system14151617, and therefore evaluation of circadian phenotypes is crucial for understanding the pathophysiology of CRSDs. The intrinsic circadian period, τ (the free-running period of circadian rhythms in the absence of external cues), is considered to be a critical factor in the pathophysiology of CRSDs. "
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    ABSTRACT: Evaluation of circadian phenotypes is crucial for understanding the pathophysiology of diseases associated with disturbed biological rhythms such as circadian rhythm sleep disorders (CRSDs). We measured clock gene expression in fibroblasts from individual subjects and observed circadian rhythms in the cells (in vitro rhythms). Period length of the in vitro rhythm (in vitro period) was compared with the intrinsic circadian period, τ, measured under a forced desynchrony protocol (in vivo period) and circadian/sleep parameters evaluated by questionnaires, sleep log, and actigraphy. Although no significant correlation was observed between the in vitro and in vivo periods, the in vitro period was correlated with chronotype, habitual sleep time, and preferred sleep time. Our data demonstrate that the in vitro period is significantly correlated with circadian/sleep preference. The findings suggest that fibroblasts from individual patients can be utilized for in vitro screening of therapeutic agents to provide personalized therapeutic regimens for CRSD patients.
    Scientific Reports 06/2013; 3:2074. DOI:10.1038/srep02074 · 5.58 Impact Factor
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