Circadian rhythm sleep disorder

Circadian rhythm sleep disorder
Classification and external resources
ICD-10	G47.2
ICD-9	327.3, 780.55
MeSH	D021081

Circadian rhythm sleep disorders are a family of sleep disorders affecting, among other things, the timing of sleep. People with circadian rhythm sleep disorders are unable to sleep and wake at the times required for normal work, school, and social needs. They are generally able to get enough sleep if allowed to sleep and wake at the times dictated by their body clocks. Unless they also have another sleep disorder, their sleep is of normal quality.

Humans, like most animals and plants, have biological rhythms, known as circadian rhythms, which are controlled by a biological clock and work on a daily time scale. These affect body temperature, alertness, appetite, hormone secretion etc. as well as sleep timing. Due to the circadian clock, sleepiness does not continuously increase as time passes. A person's desire and ability to fall asleep is influenced by both the length of time since the person woke from an adequate sleep, and by internal circadian rhythms. Thus, the body is ready for sleep and for wakefulness at different times of the day.

Sleep researcher Yaron Dagan in Israel states that "[t]hese disorders can lead to harmful psychological and functional difficulties and are often misdiagnosed and incorrectly treated due to the fact that doctors are unaware of their existence."^[1]

Types of circadian rhythm sleep disorders

Extrinsic type

Two of these disorders are extrinsic (from Latin extrinsecus, from without, on the outside) or circumstantial:

• Jet lag, which affects people who travel across several time zones.
• Shift work sleep disorder, which affects people who work nights or rotating shifts.

Intrinsic type

Four of them are intrinsic (from Latin intrinsecus, on the inside, inwardly), "built-in":

• Delayed sleep phase syndrome (DSPS), characterized by a much later than normal timing of sleep onset and offset and a period of peak alertness in the middle of the night.
• Advanced sleep phase syndrome (ASPS), characterized by difficulty staying awake in the evening and difficulty staying asleep in the morning.
• Non-24-hour sleep-wake syndrome (Non-24), in which the affected individual's sleep occurs later and later each day, with the period of peak alertness also continuously moving around the clock from day to day.
• Irregular sleep-wake rhythm, which presents as sleeping at very irregular times, and usually more than twice per day (waking frequently during the night and taking naps during the day) but with total time asleep typical for the person's age.

Normal circadian rhythms

Typical features of a normal cicadian rhythm, including a bedtime of 22:00.

Among people with healthy circadian clocks, there is a continuum of chronotypes from "larks", "morning people", who prefer to sleep and wake early, to "owls", "evening people" or "night people", who prefer to sleep and wake at late times. Whether they are larks or owls, people with normal circadian systems:

• can wake in time for what they need to do in the morning, and fall asleep at night in time to get enough sleep before having to get up.
• can sleep and wake up at the same time every day, if they want to.
• will, after starting a new routine that requires their getting up earlier than usual, start to fall asleep at night earlier within a few days. For example, someone used to sleeping at 1 a.m. and waking up at 9 a.m. begins a new job on a Monday, and must get up at 6 a.m. to get ready for work. By the following Friday, the person has begun to fall asleep at around 10 p.m., and can wake up at 6 a.m. feeling well-rested. This adaptation to earlier sleep/wake times is known as "advancing the sleep phase." Healthy people can advance their sleep phase by about one hour each day.

Researchers have placed volunteers in caves or special apartments for several weeks without clocks or other time cues. Without time cues, the volunteers tended to go to bed an hour later and to get up about an hour later each day. These experiments appeared to demonstrate that the "free-running" circadian rhythm in humans was about 25 hours long. However, these volunteers were allowed to control artificial lighting and the light in the evening caused a phase delay. More recent research shows that adults of all ages free-run at an average of 24 hours and 11 minutes. To maintain a 24-hour day/night cycle, the biological clock needs regular environmental time cues or Zeitgebers, e.g., sunrise, sunset, and daily routine. Time cues keep the normal human circadian clock aligned with the rest of the world.^[2]

Circadian rhythm abnormalities

Non-24-hour sleep-wake syndrome and other persistent circadian rhythm sleep disorders are believed to be caused by an inadequate ability to reset the sleep/wake cycle in response to environmental time cues. These individuals' circadian clocks might have an unusually long cycle, and/or might not be sensitive enough to time cues. People with DSPS, more common than Non-24, do entrain to nature's 24 hours, but are unable to sleep and awaken at socially preferred times, sleeping instead, for example, from 4 a.m. to noon. According to doctors Cataletto and Hertz at WebMD, "Altered or disrupted sensitivity to zeitgebers is probably the most common cause of circadian rhythm disorder."^[3]

As of October 1, 2005, the diagnostic codes for circadian rhythm sleep disorders were changed from the 307-group to the 327-group in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The DSM updated to agree with the International Classification of Diseases (ICD-9). The new codes reflect the moving of these disorders from the Mental Disorders section to the Neurological section in the ICD.^[4]

Treatment for circadian rhythm sleep disorders

Possible treatments for circadian rhythm sleep disorders include:

• Behavior therapy where the patient is told to avoid naps, caffeine, and other stimulants. They are also told to not be in bed for anything besides sleep and sex.
• Bright light therapy is used to advance or delay sleep, depending on how the circadian rhythm is shifted. Patients are exposed to high-intensity light (up to 10,000 lux) for a duration of 30–60 minutes at a time, the time of day depending on whether an advance or a delay is required.
• Medications such as melatonin, a naturally occurring sleep aid, or other short term sleep aids or wake-promoting agents can be beneficial. Tasimelteon has been proven effective in Phase III trials.
• Sleep phase chronotherapy progressively advances or delays the sleep time by 1–2 hours per day.^[5]

See also

• Chronobiology
• Chronotype
• Phase response curve
• Sleep diary
• Sleep medicine

References

1. ^ Dagan, Yaron (February 2002). "Circadian rhythm sleep disorders (CRSD)" (Abstract). Sleep Medicine Reviews (Elsevier) 6 (1): 45–54. doi:10.1053/smrv.2001.0190. PMID 12531141. http://www.smrv-journal.com/article/S1087-0792(01)90190-X/abstract. Retrieved 2010-10-13. 
2. ^ National Institutes of Health. "Sleep - Information about Sleep". http://science.education.nih.gov/supplements/nih3/sleep/guide/info-sleep.htm. Retrieved 2007-01-28. 
3. ^ Cataletto, Mary E.; Hertz, Gila (Updated 2005-09-07). "Sleeplessness and Circadian Rhythm Disorder" (Free registration required). eMedicine from WebMD. http://www.emedicine.com/neuro/TOPIC655.HTM. Retrieved 2008-07-20. 
4. ^ First, Michael B. (2005). "New Diagnostic Codes for Sleep Disorders". American Psychiatric Association. http://psych.org/MainMenu/Research/DSMIV/DSMIVTR/CodingUpdates/NewDiagnosticCodesforSleepDisordersEffectiveOctober12005.aspx. Retrieved 2008-08-08. 
5. ^ http://my.clevelandclinic.org/Documents/Sleep_Disorders_Center/Circadian_Rhythm.pdf The Cleveland Clinic Guide to Sleep Disorders by Nancy Foldvary-Schaefer, DO

External links

• Circadian Rhythm Sleep Disorder on Psychnet-UK
• An American Academy of Sleep Medicine Review: Circadian Rhythm Sleep Disorders: Part I, Basic Principles, Shift Work and Jet Lag Disorders. PDF, 24 pages. November 2007.
• An American Academy of Sleep Medicine Review: Circadian Rhythm Sleep Disorders: Part II, Advanced Sleep Phase Disorder, Delayed Sleep Phase Disorder, Free-Running Disorder, and Irregular Sleep-Wake Rhythm. PDF, 18 pages. November 2007.
• An American Academy of Sleep Medicine Report: Practice Parameters for the Clinical Evaluation and Treatment of Circadian Rhythm Sleep Disorders, November 1, 2007
• NASA Sleep-Wake Actigraphy and Light Exposure During Spaceflight-Long Experiment
• An active mailing list for peer support and information