Insomnia due to “body clock” problem (delayed sleep phase syndrome)

Miss Petra is a 15 year old young teenager who is referred because of severe difficulty initiating sleep over the last couple of years even though even as a young girl she used to go to sleep no sooner than 11.30pm-midnight. Currently Petra would go to bed about midnight but she would not be able to fall asleep until about 3-4am. Consequently she would sleep in until 11am, sometimes 2-3pm. As a consequence of this problem with sleep she had to abandon school because of the inability to stay awake at school and perform. Because of the poor performance and the inability to continue school she has become depressed and somewhat blamed by the family for being lazy and not sufficiently motivated. She was on an antidepressant (Cipramil™ 20mg in the morning). She is a non-smoker with no history of recreational drug use and she would take less than one caffeinated beverage per day. There was a family history of depression in her mother. Mother and father were separated.

Here the clinical picture is very much in keeping with a body clock problem that the health professional refers to as delayed sleep phase syndrome. In this condition the person is unable to fall asleep before midnight and more commonly before 1-2am and in more severe cases, like Petra, 4-5am. Once sleep is started it tends to be maintained smoothly after that. However, given the time of sleep onset the person tends to sleep until midday, sometimes 2pm. With this kind of body clock the person is unable to attend school and if they do attend school they are so sleepy that they cannot learn. Therefore it is important that this condition is recognized early so that the person is not disadvantaged in their school education.

In this situation a complicating factor is the negative consequences both in terms of family relationships and school for the person, who has become secondarily depressed and sometimes, like in this case, inappropriately accused of not being motivated enough.

There was no need for formal assessment as the clinical picture is sufficient to clarify the reason for the difficulty initiating sleep.

Petra was started on restriction of time in bed whereby she would go to bed no sooner than half past midnight and she had to get up by 7am irrespective of the amount of sleep obtained. She was asked to minimize any light after 11pm. However, bright light was encouraged after 7am. She was also started on 3mg of Melatonin at 9pm (3 hours before intended bedtime). The program was continued for about 2 weeks and then bedtime was moved slightly earlier around midnight. If sleep onset was achieved within half an hour of going to bed, then bedtime would be further anticipated 15 to 30 minutes earlier, such as 11.30pm. It was very important to maintain wake-up time at 7am irrespective of how much sleep she obtained.

At follow-up about 4 weeks later sleep onset was around midnight and sleeping through until 7am. For a person of 15 years of age 8 hours is probably still short of the requirement but was much improved compared to prior starting treatment. The patient was reassessed again 4 weeks later with the ability to fall asleep by 11pm and getting up at 7am. She now plans to restart study at TAFE. The antidepressant was also phased out over a period of a few weeks.

It was very important for this young teenager to understand that there was a physiological reason why she could not fall asleep. It was not a matter of unwillingness and it was definitely not a matter of being lazy. This was also to the relief of the parents who felt somewhat guilty of unjustly accusing the young daughter.

The problem of delayed sleep phase syndrome (the inability to fall asleep until the early hours of the morning) is very common in teenagers who have a series of factors that are working against their ability to fall asleep. To start with, the body clock of teenagers tends to move progressively later, so that physiologically they do not feel sleepy until late in the evening. By the same token the schools demand requires that they wake up in the morning earlier than they would otherwise and this causes chronic lack of sleep.

Other factors such as peer pressure, television and the Internet also contribute to a late bedtime.

One potential resistance to the above treatment, which however was not the case in this patient, is the objection of evenings out on weekends. The possibility of staying out until 4am on Friday and Saturday is not negated by the treatment. If a young person like Petra were to stay up until 2-3am on weekends she would still need to get up at 7am so that the body clock would immediately catch up the following night. However, if the person sleeps in on weekends until midday then there is a progressively more shifting of the body clock later and later at night, which would worsen their body clock problem.

It should also be recognized that the person suffering from delayed sleep onset needs to be motivated in wanting to do something about it.

Insomnia due to “body clock” problem (advanced sleep phase)

Mrs. Debbie is a 70-year-old lady who had difficulty maintaining sleep over the last 3 years.

She described daytime tiredness over at least the last few years. She is known to be a snorer but not every night and there is no history of stopping breathing.

She normally goes to bed around 8-8.30am and falls asleep within 30 minutes. She seems to be sleeping reasonably undisturbed until about 3am. After she wakes she has difficulty going back to sleep and she dozes on and off until 6 am when she gets up. Initially she feels refreshed, however, as the day passes she gets progressively sleepier and in the early afternoon she has the need to take a nap for about 30 minutes. She has been drowsy driving and sometimes while in company of other people.

A simple screening test at home (oximetry, an oxygen monitor) revealed no evidence of sleep apnea although she is a snorer. She has no symptoms suggestive of anxiety or depression. She is married in a satisfactory relationship.

Her diabetes is well controlled on medication.

The picture here is very much in keeping with a body clock problem, which we described as advanced sleep phase. This refers to the fact that the person tends to be ready to fall asleep early in the evening, sometimes 7pm or 8pm. Waking up at 3am Mrs. DB would have slept approximately 7 hours fulfilling her sleep requirement and therefore having major difficulty falling asleep again. However, waking at 3am each morning means a very long day and by the time the early afternoon arrives the person feels the need to nap.

In this case the difficulty maintaining sleep is related to a very early (extremely early) body clock, which is the opposite of the previous case.

Having understood the origin of the problem, we implemented a strategy of slowly delaying bedtime half an hour every week until she was physically in bed around 10.30-11pm. We also suggested having a well-lit room in the evening, because bright light helps delaying sleep onset. We also prescribe Melatonin 3mg at 7am. The combination of slowly delaying bedtime half an hour every week plus the use of light in the evening tends to move the body clock progressively later. By the same token the use of Melatonin in the morning tends to delay sleep onset in the evening. The effect of melatonin depends on the time of the day it is taken. In fact if taken at the wrong time of the day it has no effect at all or it may even worsen sleep.

After about 3 months of this strategy she reported being able to go to bed around 10pm and waking up around 5am which was better sleep structure than before. She felt more alert during the day.

This is another example of how insomnia, in this case difficulty maintaining sleep, was actually related to a body clock problem. Other causes of fragmentation of sleep such as sleep apnea or emotional issues such as depression were excluded.