xxxii. Chronotherapies for DSPS

3 March 2007 at 07:06 | Posted in Circadian rhythm | 10 Comments
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There are two forms of chronotherapy in use as treatments for DSPS. Since it is difficult or impossible to move sleep time to earlier in the night, an attempt can be made to sleep later than usual, by the one or the other system, until sleep and wake times are as desired.

(Note: The term “chronotherapy” can also refer to the optimization of schedules for administering medication. That is unrelated to its use here.)

1. The traditional method has been to stay up two or three hours later each night until one has gone ’round the clock. One might on subsequent days go to sleep at 6 a.m., 9 a.m., noon, 3 p.m., 6 p.m. and 9 p.m. It would then be wise to establish a bedtime of 9 p.m. for some days before easing toward the desired bedtime of 10 or 11 p.m.

This requires a week or more of strict self-discipline and a cooperative family. Maintaining the new bedtime requires very rigid discipline, and most people find that the effects may last from a few days to a couple of months at best, before the natural late night sleep time reasserts itself. There are people who routinely prepare for a daytime seminar or a holiday trip to the in-laws in this way.

IMPORTANT UPDATE:  See also post no. 55 about chronotherapy.

2. An article from Sleep Review, 2003, tells of a lesser known form. There we learn of a 16-year-old boy who had had DSPS for years. He slept nicely from 3 a.m. to noon but his mother had trouble getting him up for school and he dozed during breakfast, on the ride to school and during morning classes. The boy’s history and sleep log showed classic DSPS. He was active, not shy and not depressed.

“DSPS would not be problematic in a world without appointments and schedules. It becomes an issue when it results in conflict at school or work, or with family. Some adolescents are content with their DSPS and have no real desire to change. This perspective presents a serious barrier to therapy. Ultimately, it falls on patients to decide whether they are willing to make the effort and sacrifices required. We stress to families up front that DSPS can be alleviated in a motivated teenager, but therapy is “active” and not “passive.” It cannot be imposed on someone who is not willing to make substantial changes in lifestyle and habits.”

A modified chronotherapy was devised by M. J. Thorpy et al in 1988, apparently specifically for adolescents. It is called controlled sleep deprivation with phase advance, SDPA, and it is designed to be less disruptive to families and the school or work schedule while still taking advantage of the fact that most people find it easier to stay up late than to fall asleep early.

SDPA, step one: the patient sleeps regularly for a week on his natural schedule, in order to start treatment rested.

Step two: a night of total sleep deprivation followed by advancing bedtime by 90 minutes.

Step three: the new bedtime is observed for six days to consolidate the pattern.

Step four: the process of one night of total sleep deprivation followed by advancing the bedtime by 90 minutes is repeated. The process is continued every week until a target bedtime and wake-up time are attained.

Step five calls for maintaining the regular bedtime and rise-time once reached, to prevent relapse of DSPS. 

Conclusion
“Our patient responded to a trial of SDPA, though success required three attempts. Social events and failing to refrain from naps during the day interfered with the first trial. During the next attempt, he developed some performance anxiety around falling asleep even after being sleep deprived. He would lie in bed and worry about not being able to fall asleep. In this circumstance, we felt justified in adding a short course of zolpidem at bedtime for 1 week in combination with SDPA, and he successfully reset his schedule to a 10:30 pm bedtime and 7:00 am rise-time. The family enlisted help from his friends to reschedule their social activities, and this helped the therapy plan move ahead as well. 

 

“It is likely that we have not heard the last from our young man. DSPS patients have a high rate of recidivism, particularly when opportunities to fall off schedule (vacation, travel, college, final examinations, social events, and jobs) present themselves. It is our hope that we succeeded at least in giving our patient the tools he needed to correct his sleep troubles and that he will remember them and know what he needs to do the next time problems arise.” 

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This was an interesting approach. It mirrors somewhat my own tactic which I call my 36-hour trick. At times, almost once a week, I feel a need for a long sleep, 11-12 hours. This can only be attained by staying up one whole night and going to bed very early the next night. It does not, however, get me to bed earlier the following nights. It just allows me to feel rested and healthy for a few days. I have my doubts that the “new” chronotherapy (no. 2) would last any longer than the old, without the aid of melatonin and a light box.  

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Next:  xxxiii. Owls of the World, Unite!

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10 Comments »

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  1. I tried this many a time and it only wacked my rhythm out more. No matter how little sleep I got I still could not get to sleep earlier I was just more tired and sleep deprived. If I had to force myself awake earlier for work I had sacrificed the reserves of energy I needed. Maybe for someone young this is an option but as I get older I find I just need to sleep when I can.

  2. Sometimes I wonder if there might be a lot of people out there who really have this thing licked with one or more of the management therapies. It’s theoretically possible that there are, and that’s why we never hear from them. But I doubt it. If I’d got it licked, I’d be all over the place telling people how.

    Dagan and Abadi in 2001 proposed terminology for and recognition of what they called “SWSD disability” (Sleep-Wake Schedule Disorder disability) for incurable cases. It is “an untreatable pathology of the circadian time structure,” they say, and: “It is imperative that physicians recognize the medical condition…” It doesn’t seem as though the rest of the research and medical communities have caught up with them, unfortunately.

    Thanks for reading and commenting here!

  3. This blog entry is so interesting. Thank you so much for the information concerning SDPA! I have decided to try this method on my own (I am on day 3 now of the first phase) and simply having set times to sleep and wake have made a large difference. For many times, I went to sleep whenever I could (I am rather busy most of the time so I felt I couldn’t have a set bedtime), usually sometime in the early morning, and woke up whenever I felt that I had “rested” enough, which was typically anywhere from 6 to 9 hours from when I went to bed. I’d wake up feeling groggy and unrested, in fact. I wake up feeling pretty good now! So, if I don’t get anything else out of this method, I’ll at least know the real difference that having a set sleep and wake time makes.

  4. Thanks for writing, and good luck!

  5. Hi, glad I found this blog.

    Could melatonin be used to accelerate the traditional form of chronotherapy? For instance, by taking some at bedtime, it might further lengthen the cycle by a few hours, and thus achieve the roll-over in a few days. This would make the process vastly more convenient.

  6. Maybe it could. I suspect that getting the timing right would be as difficult as it is with jet lag, making the idea not too practical. (I’ve never tried chronotherapy. The thought that it might push me over into Non-24 is too scary and I feel I’m on the threshold anyway.)

  7. I’ll be posting about your 36-hour trick one of these days. As you know, I have some ideas about what’s going on there.

    But in the meantime, I think this SPDA is something a bit different. What strikes me is that they do not talk about the lighting conditions during the SPDA treatment, even though the subject will be awake during the most powerful part of the light PRC. It might be that light which is causing the phase advance.

    I says this in part because of a couple of studies, including one by Dijk that shows a pronounced phase delay after repeated nights of sleep deprivation when done under dim light conditions.

    1: Cajochen C, Jewett ME, Dijk DJ. Human circadian melatonin rhythm phase delay during a fixed sleep-wake schedule interspersed with nights of sleep deprivation. J Pineal Res. 2003 Oct;35(3):149-57. PubMed PMID: 12932197.

  8. […] Treatments for circadian sleep disorders fall into three general categories. The first combines phototherapy and scototherapy, that is treatment with light and dark.  The second is pharmacotherapy, usually using melatonin or one of its drug analogs. The third treatment is what I will discuss today and is known as chronotherapy. […]

  9. The article linked above in #2 IS available in the Internet Archive, the link for it is http://web.archive.org/web/20120423172018/http://www.sleepreviewmag.com/issues/articles/2003-09_08.asp

    Perhaps this entry could be updated to reflect that permanent archived link?

  10. Thanks so much, Chandra! Fixed.


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