Opinion

‘It’s not insomnia’: Shining a light on delayed sleep phase syndrome


Evelyn Lewin


6/11/2019 3:12:25 PM

Patients with circadian rhythm disorders are commonly mislabelled as having insomnia, but the two conditions are managed very differently, Dr Evelyn Lewin writes.

Man struggling to sleep
The internal body clock of a person with a circadian rhythm disorder is out of sync with their desired social clock.

For most of my life, I’ve called myself an insomniac.
 
After all, I struggle to fall asleep. Then, come the next day, I struggle to wake up.
 
I have no other comorbidities contributing to my sleep issues, and simply put my problems down to initial insomnia.
 
Because I am a GP and well-acquainted with ‘sleep hygiene’ methods, I often try to employ these techniques to help me nod off.  
 
They seem to help for a short period of time, but my insomnia always comes back.
 
It wasn’t until I spoke to sleep consultant Dr David Cunnington a few years ago that I realised I do not, in fact, have insomnia.
 
Rather, I have a circadian rhythm disorder.
 
Delayed sleep phase syndrome, to be exact.
 
If you haven’t heard of this condition, Dr Cunnington isn’t surprised.
 
‘It’s not taught in undergraduate medical school. It’s not taught,’ he told me.
 
‘There’s less than two hours about sleep in the undergraduate curriculum, even now.’
 
Dr Cunnington said that teaching tends to focus on the formulaic 50-year-old truck driver with a BMI of 50 who isn’t sleeping well. 
 
‘It’s confined to recognising the absolutely stereotypical sleep apnoea and really anything else outside of that. There’s just not space in the curriculum,’ he said.
 
So what is delayed sleep phase syndrome?
Dr Cunnington explains that it is a circadian rhythm disorder whereby someone’s internal body clock – referred to as their ‘biological time’ – is out of sync with their desired social clock.
 
In other words, there’s a mismatch between when a patient wants to sleep and when they’re naturally inclined to do so.
 
‘And it’s called “delayed” sleep phase because, essentially, there’s a delay between the biological and the social clock,’ Dr Cunnington said.
 
‘For example, someone who wishes to go to bed at 10.00 pm and be asleep shortly after and arise at 6.00 am may not naturally feel sleepy until 2.00 am and may not naturally awaken until 10.00 am.
 
‘So when the alarm goes at 6.00 am they feel heavy-headed, as if they’re waking in the night because literally it is the middle of their biological night.’
 
(I’d like to pause for a second and appreciate that. When my alarm goes off every morning I feel like I’m being yanked awake in the middle of the night because, for people with delayed sleep phase syndrome, it literally is the middle of our night.)

Dr-Cunnington-article.jpg
Sleep consultant Dr David Cunnington says it is common for him to receive referrals from GPs for insomnia for patients who actually have circadian rhythm disorders.

If you think this is a rare problem, think again.
 
Dr Cunnington describes it as ‘very common’.
 
‘In a population, around 10% have enough of a night owl tendency that it interferes with their day-to-day functioning,’ he said.
 
‘So there’s enough separation between their desired bedtime, or “social” time, and their biological time that it causes trouble either getting to sleep or getting up in the morning.’
 
While people can struggle with circadian rhythm disorders at any stage in life, Dr Cunnington said it is more prevalent in adolescents, and in those with mental health issues such as depression.
 
And yet, I wonder how many GPs see patients with circadian rhythm disorders and mislabel them as having insomnia.
 
According to Dr Cunnington, that happens all the time.
 
After all, with a paucity of education on the topic, and chronic insomnia listed as the third most common psychological reason for GP consultations, there’s bound to be misdiagnoses galore.
 
Dr Cunnington said it is ‘quite common’ for him to receive referrals from GPs for insomnia for patients who, in fact, have circadian rhythm disorders.
 
How can a GP determine whether a patient has a circadian rhythm disorder rather than insomnia?
Dr Cunnington says a good starting point is to ask your patient what time they go to bed – and why.
 
‘If the answers is, “I go to bed at that time because I need to be up at 7.00 am”, it’s really the wrong answer and the wrong time to go to bed,’ he said.
 
‘Really, the only reason to go to bed should be, “Because I feel sleepy; my body’s telling me that it’s time to go to sleep”.
 
‘Any other cue to go to bed is really an environmental or social cue, rather than an intrinsic or biological cue.’
 
By this stage in our conversation, I am desperate to hear how I can actually fix my circadian sleep issues (or, more realistically, at least help improve my situation).
 
Sadly, there is no neat answer to my woes.
 
Ideally, Dr Cunnington said, people should follow their biological cues.
 
So, if I’m not tired enough to go to sleep until 2.00am, and I can then sleep well until 10.00 am, I should do that.
 
That’s wonderful in theory, I say to Dr Cunnington. Yet my children and my job both require me to be awake and functioning well before 10.00 am.
 
And his next piece of advice doesn’t make me much happier, to be honest.
 
Instead of trying to coerce myself to sleep when I’m not ready, it’s time to accept the fact that my innate sleep habits don’t match up with societal norms – and to adjust my expectations accordingly.
 
‘So, getting people to recognise that if you’re a natural late-night type and you’ve got primary school kids who are natural early morning types, it’s going to hurt,’ he said.
 
(It does.)
 
Once you manage your expectations, Dr Cunnington believes we can be more ‘rational’ about our sleep patterns.
 
Sleeping pills aren’t the answer, either, in case you were wondering.
 
‘Sedative hypnotics may force somebody to get to sleep, but it won’t actually address that mismatch between social time and biological time,’ Dr Cunnington said.
 
Sure, using benzodiazepines in the short term may help people with circadian rhythm disorders fall asleep faster. But as soon as they are ceased, Dr Cunnington says, patients are ‘back in the same situation they were always in because nothing’s changed’.
 
That doesn’t mean there’s nothing patients with delayed sleep phase syndrome can do to help their situation.
 
Dr Cunnington says sleep hygiene plays a role, especially when it comes to avoiding blue light (such as from one of our many screens) before bed, and ensuring adequate sunlight exposure in the morning to aid with melatonin production.
 
Another way to manage this condition is to encourage patients with delayed sleep phase syndrome to factor in extra time to snooze when possible, scheduling extra ‘downtime’ and naps to compensate for sleeplessness.
 
I must admit, it’s a little frustrating that there’s no ‘better’ answer for people like me.
 
But, as Dr Cunnington says, it’s better to help people manage their expectations than ‘get constantly frustrated trying to put a square peg in a round hole’.
 
While learning to do that, I’m also going to stop calling myself an insomniac.

Login below to join the conversation.



circadian rhythm delayed sleep phase syndrome insomnia sleep



Login to comment

SMP   7/11/2019 8:23:39 AM

I find that delayed sleep phase is simple but not necessarily easy to solve. It requires the discipline of waking early in the morning to obtain plenty of natural sunlight outside (or at least with no glass) and then periodically during the day. Avoidance of artificial light at least two hours before bedtime is required as mentioned in the article. We did not evolve with all this artificial light. The suprachiasmic nucleus needs to be provided with the appropriate light cues. Last night I went to sleep at 9pm and was up at 5. Sleep pressure was very good because I try to always be up around sunrise. The problem is social expectations at the end of the day.


Dr Nicola Pennell   7/11/2019 9:13:18 AM

There's a great book about sleep called "Why we Sleep" by Matthew Walker (sleep neuroscientist in USA) which explains really well and relatively simply some of these sleep issues. Good for GP and patient alike - also addresses effects of alcohol, caffeine and medication on sleep, shift work, schooling timing, pain and sleep. Highly recommended.


Dr Nicola Pennell   7/11/2019 4:00:50 PM

There's a great book about sleep called "Why we Sleep" by Matthew Walker (sleep neuroscientist in USA) which explains really well and relatively simply some of these sleep issues. Good for GP and patient alike - also addresses effects of alcohol, caffeine and medication on sleep, shift work, schooling timing, pain and sleep. Highly recommended.


Dr Kate   7/11/2019 6:30:50 PM

I wonder then how much benefit people with this condition will get from short or long term melatonin supplements (which can be useful in my experience with temporary circadian cycle issues eg jet lag ) when the 'social cycle' just can't realistically be made to fit with the biological - any comment on this Drs Lewin or Cunnington?


Dr Hume Arthur John Rendle-Short   7/11/2019 7:53:42 PM

From the article: "Dr Cunnington says sleep hygiene plays a role, especially when it comes to avoiding blue light (such as from one of our many screens) before bed, and ensuring adequate sunlight exposure in the morning to aid with melatonin production."

If light causes the production of melatonin, why do we give it at night


Dr Kevin Jenn-Lii Ng   11/11/2019 7:41:30 AM

My testimonial for complete cure: Try mindfulness meditation, or even better with biofeedback via a headgear ‘muse’, it was more effective than adjust/negotiate expectations, white light therapy etc. I was diagnosed with DSPS and struggled through schools, uni, resident years until it was pretty much in remission . Occasionally recurs once a month but it wasn’t hard to manage it once you’ve reached a stage of familiarity with meditation .