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The Sleep Disorder You Might Be Missing
Every living creature, from deep sea fishes to microscopic single-celled terrestrial organisms, has an innate biological clock. For us surface dwellers, our rhythms undulate to the beat of the earth’s dark and light cycles. Light is the most powerful zeitgeber, or time giver, that regulates the internal clock. In this era of breaking news and binge watching, we are bombarded with constant exposure to artificial light, resulting in disruption of our natural body rhythms. Disturbances in the circadian rhythm can result in metabolic diseases, obesity, cancer, and mental health disorders. Despite the growing appreciation of chronobiology, circadian disorders are frequently missed in clinical practice.
Every living creature, from deep sea fishes to microscopic single-celled terrestrial organisms, has an innate biological clock. For us surface dwellers, our rhythms undulate to the beat of the earth’s dark and light cycles. Light is the most powerful zeitgeber, or time giver, that regulates the internal clock. In this era of breaking news and binge watching, we are bombarded with constant exposure to artificial light, resulting in disruption of our natural body rhythms. Disturbances in the circadian rhythm can result in metabolic diseases, obesity, cancer, and mental health disorders. Despite the growing appreciation of chronobiology, circadian disorders are frequently missed in clinical practice.
Delayed Sleep Phase Syndrome (DSPS), also known as Delayed Sleep-Wake Phase Disorder, is one of the most commonly encountered circadian rhythm disorders in clinical practice and is often misdiagnosed as sleep-onset insomnia. DSPS should be suspected in those who complain of consistent patterns of sleep onset significantly later than the desired or conventional time. Patients with DSPS may also complain of problems with social and occupational functioning such as chronic tardiness to work or school, impaired academic or work performance, conflicts with parents or partners regarding wake time, and sleep deprivation. Common psychiatric comorbidities include depression, seasonal affective disorder, bipolar I disorder, obsessive compulsive disorder, and attention deficit hyperactivity disorder. A higher degree of circadian misalignment may be correlated with more severe depression and poorer response to treatment with antidepressant medications. Furthermore, it has been shown that patients with DSPS have a threefold higher prevalence of comorbid seasonal affective disorder compared to controls.
So, how do we differentiate DSPS from insomnia? A good clinical history is the cornerstone of psychiatric diagnosis and the diagnosis of DSPS is no different.
Diagnostic criteria according to the third edition of the International Classification of Sleep Disorders (ICSD-3) is as follows:
The phase of the major sleep episode shows a significant delay in relation to the desired or required sleep time and wake-up time, as evidenced by a chronic or recurrent complaint by the patient or a caregiver of inability to fall asleep and difficulty awakening at a desired or required clock time.
The symptoms are present for at least three months.
When patients are allowed to choose their ad libitum schedule, they will exhibit improved sleep quality and duration for age and maintain a delayed phase of the 24-hour sleep-wake pattern.
Sleep log and, whenever possible, actigraphy monitoring for at least seven days demonstrate a delay in the timing of the habitual sleep period. Both work or school days and free days must be included within this monitoring.
The sleep disturbance is not better explained by another current sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.
Zeitgebers and lifestyle should be also assessed including use of caffeine and stimulants, diet, the timing of meals, exercise, work/school/activity schedules, evening light exposure, and use of screens. Sleep diaries are useful adjunct to the clinical history and are recommended to evaluate the sleep schedule. The AASM sleep diary is free to download and provides two weeks’ worth of data. Actigraphy provides an accurate measure of sleep-wake cycles but may not be readily available in clinical practice. Polysomnography is not indicated unless there is clinical suspicion for another sleep disorder such as obstructive sleep apnea.
Once a diagnosis is established, behavioral modifications should be initiated in order to facilitate advancement of the circadian phase. Patients should be advised to minimize use of stimulants, avoid daytime naps, reduce light and screen exposure in the evenings, and avoid stimulating activities at least 2 hours before the time of desired sleep onset. Along with behavioral changes, melatonin and light are powerful body clock regulators that may be considered in the treatment plan. Short-term (<3 months) use of melatonin at a dose of 0.5mg, timed strategically 1.5 to 2 hours before the desired time of sleep onset can “pull” sleep earlier. Morning light therapy with a light box is effective for “pushing” back the wake time. It is recommended that patients start with using the light box at their natural wake time, then advance use of the box by 15 to 30 minutes each morning until the target wake time is reached. Use of hypnotics or sleep aids is not recommended. Consistency in following these strategies is the key to successfully shifting the sleep-wake cycle to align with one’s work or school schedule.
By recognizing and treating circadian rhythm disorders, we can help improve quality of life, reduce the risk of medical and psychiatric comorbidity and restore a natural, balanced body rhythm. Now, that’s something that will help us all sleep better at night.
Rishab Gupta is a third year resident in psychiatry at SUNY Downstate Medical Center in Brooklyn. He is also enrolled in a PhD in Neural and Behavioral Sciences at Downstate. He graduated from All India Institute of Medical Sciences (AIIMS), New Delhi in 2008. Being extremely interested in understanding human behavior since his medical school days, he joined Psychiatry residency at AIIMS in 2009. After finishing his training, he continued to work in the Department of Psychiatry at AIIMS as a trained psychiatrist. He is very passionate about academics and loves teaching and pursuing clinical research. He has presented his work at multiple national and international platforms and published numerous papers in different domains of psychiatry. Because of his unquenched thirst for learning he joined SUNY Downstate Medical Center as a Psychiatry resident in 2016. After graduating, he plans to pursue fellowship in Neuropsychiatry because of his active interest in disorders lying at the interface of Neurology and Psychiatry. He aims to be an academician and pursue research into the neurobiology of frontotemporal dementia, and psychotic disorder. When he is not in the clinic or learning psychiatry, he enjoys reading trivia, making jokes, doing social networking, trekking, listening to Punjabi music, and bingeing on various TV shows and movies.
Nwayieze Ndukwe
Dr.Nwayieze C. Ndukwe, MD, MPH, is a psychiatrist based in New York and New Jersey who enjoys exploring the interesection of mental health and popular culture. Dr.Ndukwe serves a associate professor at Mount Sinai Hospital systems in New York City and Mountainside Hospital in Montclair. Dr.Ndukwe was trained at Mount Sinai Beth Israel, and is board certified in Psychiatry by the ABPN. Dr.Ndukwe also holds a Master's in Degree in Public Health from Rutgers University.
Candace Good
Dr. Good specializes in college mental health as a staff psychiatrist at Penn State Counseling and Psychological Services. She is also the founder of Sig: Wellness, LLC, an integrative psychiatry practice in State College, PA. Her office includes a mind-body studio to encourage yoga, meditation, and other healing arts for stress management. The space serves as an incubator for other female wellness practitioners to grow their presence in the community. Dr. Good welcomes freelance writing and editing projects relevant to her specialty and blogs at https://howtoshrinkashrink.com.
Dr. Good is board-certified in both general and child & adolescent psychiatry. She maintains a clinical faculty appointment with the Penn State College of Medicine, where she also completed her medical degree and residency training. Over the past 15 years, her clinical work has included care of families in both rural and underserved communities as well as academic settings. Administrative roles have included medical director at the Western Psychiatric Institute and Clinic Center for Children and Families, vice president of Sunpointe Health, and both unit director of behavioral health services and department chair of psychiatry at the Mount Nittany Medical Center. In 2017, she was elected to the Board of Trustees of the Pennsylvania Medical Society (PAMED) and was recognized as a Distinguished Fellow of the American Academy of Child & Adolescent Psychiatry (AACAP).
Dr. Good enjoys knitting and spending time with her family, especially her daughter and rescue hounds, Abbott and Flip.
Dr. Chepke attended NYU School of Medicine and completed psychiatry residency at Duke University, where he also completed undergraduate studies. He is Board Certified by the American Board of Psychiatry and Neurology and is a Fellow of the American Psychiatric Association. He currently has a private practice in Huntersville, NC, serves as medical director for a level 3 residential adolescent treatment facility, and is an Adjunct Clinical Professor of Psychiatry for the University of North Carolina-Chapel Hill Medical School at the Charlotte Campus.
Dr. Chepke has particular interests in treatment-resistant/severe persistent mental illness, as well as patients with both psychiatric and neurological disorders. He is a member of the CURESZ Foundation Clozapine Experts Panel and Tardive Dyskinesia Experts Panel, as well as a member of the International Parkinson and Movement Disorder Society. He also emphasizes engaging his patients in psychotherapy and strongly encouraging integrative approaches including physical health and wellness through exercise and dietary modification and supplementation. Dr. Chepke’s research interests are in neuropsychiatry and drug metabolism/interactions and is currently a principal investigator for several clinical trials.
Nishi Bhopal, MD is Board Certified in Psychiatry, Sleep Medicine, and Integrative Holistic Medicine. She grew up in Vancouver and completed her undergraduate studies at the University of British Columbia. Her interest in medicine and love of travel took her halfway across the globe where she graduated with a degree in medicine from the National University of Ireland, University College Cork School of Medicine. She went on to complete her Psychiatric residency training at Henry Ford Hospital/Wayne State University and then a fellowship in Sleep Medicine at Beth Israel Deaconess Medical Center/Harvard Medical School. She now calls the Bay Area home and practices outpatient psychiatry in San Francisco. Dr. Bhopal is passionate about helping her patients find health and wellbeing through a combination of modern medical science and the wisdom of traditional eastern practices.
Dr. Nissa Perez completed her undergraduate work in psychobiology at UCLA and then obtained her medical degree from University of Southern California. She completed residency at UCLA San Fernando Valley Psychiatry Training Program and is a Board Certified Psychiatrist. She worked for one year as an attending in her residency program and has been in private practice for the last four and a half years, now in San Jose, CA. She incorporates psychopharmacology and psychotherapy into her practice and draws from multiple therapeutic modalities, primarily psychodynamic and mindfulness, but also incorporates cognitive behavioral therapy.
Dr. Perez is also an avid meditator and yogi. She meditates daily, regularly practices yoga and has attended multiple silent meditation retreats. She blogs at AMindfulMD.com.
Dr. Leslie Walker obtained her MD and MS (Neuroscience) degrees from the University of Michigan. She finished residency at Johns Hopkins Hospital in 2000 and has been in solo practice since then, first in Baltimore and then in Cleveland. She has particular interests in treating women as well as physicians, and for five years served part-time as the psychiatrist for the Women's Trauma Treatment Program at the Cleveland VA Hospital. She enjoys teaching residents and medical students at Case Western Reserve University School of Medicine, and she speaks nationally to physicians on psychiatric topics, work/family balance, resilience, and self-care. She is married to an academic neurologist and has one child in college and one in graduate school, making her officially an empty nester! Next goals: starting a blog and publishing a book.
Erik Messamore, MD, PhD is an expert in the fields of psychopharmacology, complex mood disorders, psychosis and schizophrenia.
He earned a PhD in neuropharmacology from Southern Illinois University and completed a Postdoctoral Fellowship at the Karolinska Institute in Stockholm, Sweden. He received his Medical Degree from the University of Illinois and completed a residency in Psychiatry at Oregon Health & Science University in Portland.
His current research is focused on characterizing the blood flow response to niacin among people with schizophrenia. This research may ultimately improve our ability to detect schizophrenia at its very early stages and to categorize psychiatric illness along physiological lines.
He currently serves as an Associate Professor of Psychiatry at the Northeast Ohio Medical University (NEOMED) in Rootstown, Ohio. He is also the Medical Director of NEOMED’s Best Practices in Schizophrenia Treatment (BeST) Center.
He is a seasoned clinician and accomplished scientist, with a passion for improving the lives of those affected by mental illness.