xxxviii. Eveningness vs. DSPS

10 November 2007 at 07:00 | Posted in Circadian rhythm | 4 Comments
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“Well, I don’t like getting up before seven either,

but I have to, and I do.”

Implication: and you can, too.

But, is that true?

The article on Wikipedia about Chronotypes, morningness/eveningness, reports what researchers know so far about these normal variations, which have been studied since about 1970 and are measured by the Horne-Östberg questionnaire, the MEQ, a short version of which can be found online at Bruce Logie’s interesting site.

 
It can be interesting to compare normal evening types with what we know about people with Delayed Sleep-Phase Syndrome.

 
Normal, healthy sleepers can be morning types (up to 25%), intermediate types (50% or more) or evening types (up to 25%). Any of them can be classified as long sleepers or short sleepers in normal distribution. They have normal “sleep architecture”, as do most people with DSPS. 
 
Normal night owls who are good sleepers:
 
  • like to sleep in and don’t like to go to bed early.
  • are more alert in the evening than just after awakening, as opposed to morning types.
  • can take a nap at 10 a.m. or noon after a night with less sleep than usual, while morning types generally don’t want a nap until 2 p.m. or later.
  • experience both Dim-Light Melatonin Onset (DLMO) and the minimum of the daily cortisol rhythm later (clock time) than morning types.

So far, it sounds like people with DSPS are evening types, as the properties above apply to both groups. However, normal evening types:

  • after starting a new routine requiring them, for example, to start work earlier than before, will adjust their sleep-wake schedules to the new times within a few days.
  • awaken spontaneously earlier in their circadian phase than morning people; that is, the interval between the low point of the body temperature and wake time is shortest in evening types. In people with DSPS, it’s notably much longer than average.

People with DSPS do not adjust to a new schedule easily, if at all.

CRSD [circadian rhythm sleep disorders] patients differ from night or morning type people … in the rigidity of their maladjusted biological clock. While “owls” and “larks” prefer morning or evening, they are flexible and can adjust to the demands of the environmental clock. CRSD patients, on the other hand, appear to be unable to change their clock by means of motivation or education,” according to Dagan, 2002 (PDF, page 3).
 
Or, as Wikipedia puts it: Attempting to force oneself through 9 – 5 life with DSPS has been compared to constantly living with 6 hours of jet lag.”
 
Uchiyama et al, 1999, found that people with DSPS do not evidence normal recovery sleep after sleep deprivation. They conclude that “[t]his suggests that DSPS may involve problems related to the homeostatic regulation of sleep after sleep deprivation.
 
Some of the characteristics of normal evening types may or may not also be characteristic of people with DSPS. If these points have been reported in the literature about DSPS, I haven’t seen them:
  • Evening types have a core body temperature which is a bit lower than average, both day and night. Is this also true for people with DSPS?
  • Evening types have a melatonin profile which declines much more slowly after midpoint, as compared with morning types. Is this also true for people with DSPS?
  • Evening types take a long time to “get going” after awakening. In relation to the timing of spontaneous awakening, the following points contribute to this for evening types, and possibly also for people with DSPS:
  • the timing of lowest body temperature,
  • the timing of the cortisol minimum,
  • the timing of melatonin offset, and
  • the slower decline of blood levels of melatonin.  

We have a disorder which, without treatment, forces us to fall asleep even later than evening types. Simply trying to enforce conventional sleep and wake times does not advance the circadian markers. It seems almost impossible to wake us much earlier than our pre-programmed wake time (as my siblings will attest). The disorder is chronic, changing little or not at all after the age of 20.  

When normal chronotypes shift their schedules, all the body’s rhythms catch up and are synchronized to each other within a few days. In DSPS, the dissynchrony may continue as long as the shifted, “unnatural” schedule lasts, even for years or decades, leading to physical and psychological disorders.

It’s clear that people with DSPS who (try to) work days, have much the same set of problems that many shift workers have, whether these always work nights or are on a rotating schedule. However, shift workers’ problems receive sympathy and understanding while people with DSPS are commonly stereotyped as undisciplined and lazy. Dagan again (PDF, page 7), on adolescents, points out that “[f]requently, the patients’ parents, teachers, doctors, or psychologists believe that the patients’ biological sleep-wake problem and the accompanying dysfunction at school are motivational or psychological in nature, a belief that during the years, the patients tend to adapt themselves. This attitude toward CRSD patients, to which [they have] been subjected since early childhood or adolescence, adds psychological distress to the practical difficulties of coping with life.”

Like normal people, we do adjust (entrain) to the earth’s 24-hour rotation, but, without treatment, we don’t “learn” to wake up at a conventional, early time of day.

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Next:  xxxix. Guest Blogger

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xxxiv. Guest Blogger: Alan West

26 June 2007 at 17:58 | Posted in Circadian rhythm | Leave a comment
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On our ‘niteowl’ list we give support and compare experiences. That list is a life-saver.

Now and then member Alan West, casting pearls for swine, finds and uses his most talentful pen. As here (with permission) on some results of sleep deprivation:

If the early-start enthusiast managers could somehow see the condition of the insides of our heads, I wonder what would happen? There might be some rather frenzied back-pedalling, along with long and tense conferences with their respective corporate insurance providers. Of course, there might not. 

 But how do we convey an accurate impression of our mental processes after early starting? After several years of early starting? Consider a more than usually drug-soaked short story. Various things happen in a headachy blur. Extraneous characters float in and out, unexplained. Strange things hide in the corners of the vision, wriggling and twitching and occasionally offering irrelevant comments in cartoonish voices. The co-workers have become a strange colour, and several do not appear to be touching the ground. Their faces have changed, and now they resemble famous people, long-dead physicists or gargoyles. The central character has to fight down the urge to slide small pieces of paper into the great creases in the faces of these gargoyles. 

The story continues. By now the readers understand, with mounting unease, that our central character, combining the worst of the mental states of Hunter S Thompson, Thomas de Quincy, and several other notorious drug-heads or drunks, has driven to work, managed to negotiate the stairs, found their desk, and is about to work on a huge and vastly important project that will affect the happiness of the entire human race. Can they find their pen? Can they remember any single fact about the project on which they are working? Can they remember their name, or where they live? Why are the pieces of paper on their desk moving about by themselves? Is there a goat hiding near the photocopier, leering?

The story concludes with the responsibility and sobriety of the central character being reinforced. The reader now knows that our hero is clean-living, and of sensible habits. But the weird stuff continues as the hero continues to look for their pen….

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Next:  xxxv. Can one figure out one’s own rhythms?

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xxxiii. Owls of the World, Unite!

24 March 2007 at 12:57 | Posted in Circadian rhythm | 2 Comments
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In Denmark, Norway and possibly other countries ‘larks’ (early-risers) are called ‘A-people’ while ‘owls’ (late-risers) are ‘B-people’. Language is important in defining issues, so this terminology is unfortunate, I think, but it is well-established. Just the fact that there is a defining terminology in various languages is an admission that there is an issue. The common terms in English, larks for morningness and owls for eveningness, seem much less (de-)grading. 

 Danes are, in my experience, good organizers. In late December 2006, the B-Society, ‘B-samfundet’, went public and it now has nearly 4000 members and a newsletter in Danish. On its web page, its goals are defined in Danish and in English. [Update, June 2007: There’s now an international site in English: The B-Society.] There is a page for comments [now defunct, replaced by forum], which are appearing thick and fast in the Scandinavian languages as well as English and others; spam is also appearing, so something needs to be done about that.

The B-Society wants the world to please forget the archaic requirement for all work to be done while the sun is up and preferably just as soon as it’s up. When everyone must appear at work and school at the same time in the (early) morning, traffic jams result and up to half of the workers will not be performing at peak capacity for several hours yet. We’ve had electric light for well over a century, and it is past time to make some changes to everyone’s benefit.   

To quote the site (I’ve corrected their halting English some): “… it is unproductive for ‘owls’ dealing with knowledge, creativity and innovation to be at work at 8:00 a.m. without being present mentally, since their productivity peaks in the afternoon and in the evening. The different rhythms of people will generate a good bottom line in the innovation-driven society.”

One concrete project which may show some promise is awarding “certification” to employers who are friendly to “owls”, aka B-people. As they put it: “The B-Society is working with B-Certification of employers who accept and respect the working rhythm of ‘owls’. B-Certification will enable ‘owls’ to navigate in the labour market and find those workplaces that actually implement flexible working hours as well as show respect for and acceptance of the life and work rhythm of ‘owls’.
Now this is an idea whose time has come! The B-Society seems not to have heard of Delayed Sleep-Wake Syndrome (DSPS), only the eveningness of fairly normal “owls”. Yet achievement of their goals will obviously help us, too, as sleep deprivation is nasty for all of us. More power to them!
 
The chronobiologist “Coturnix” has a blog entry about the B-Society here. I borrowed his title.
And the remarkable photo of an attacking owl is the winner of National Wildlife’s 35th annual photography competition. Kim Steininger of Pennsylvania took the picture in Ontario, Canada, last winter. She noticed that one of the great gray owls was staring back at her. “I didn’t think anything of it until it started flying at me,” she says. Before getting out of the way, she captured this digital photo with a 500mm telephoto lens.

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Next:  xxxiv. Guest Blogger: Alan West

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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.” 

¤  ¤  ¤  ¤  ¤  ¤  ¤  ¤  ¤  

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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xxii. How to tackle DSPS

18 December 2005 at 12:48 | Posted in Circadian rhythm | 6 Comments
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Having a circadian rhythm disorder and not knowing what it is, is essentially different from having one and knowing something about it.  Though no two of us are alike, anyone with a disorder related to mine who has read this far, now knows something about it.  
 
Someone wrote on a message board recently:  “Wow – reading these posts is totally shocking.  It seems like I have written them all myself!  I have gone through so much of what is described here.” 
 
Adding such descriptions here, blog entries about my past troubles and struggles, already half-written in my head, is unnecessary, I think. 
 
Finally — way out in the middle of Chapter Two — it’s occurred to me that I should define who I’m writing for. 
 
You are probably over 20.  You have one heck of a time getting up in the a.m. no matter how many alarm clocks you are using (and likely not even hearing).  You are at your most alert, creative, productive and alive in the middle of the night, and you’ve been like this for years.  You’ve tried “getting to bed at a decent hour”, but for you that doesn’t mean getting to sleep right away.  However, when timed right for you, your sleep is usually good and uninterrupted for 7-9 hours.  When you do get enough sleep, timed right, you’re not unreasonably tired the rest of the day.  You suspect that you may have a circadian rhythm disorder. 
 
You may also be one of the approximately 50% of us who’ve been diagnosed with depression or anxiety.  Not all the experts agree with me ( yet Image ), but it looks like the trend is to accept that the root of the problem is the physical / chemical / genetic circadian rhythm disorder.  The mood problems follow, quite logically, because of societal expectations and pressures, often compounded by sleep deprivation. 
 
You may have gotten onto the sleeping pill merry-go-round, resulting in habituation, withdrawal, rebound etc.  (Thanking my lucky stars — I’ve never gone to a doctor who talked me into that!) 
 
You may have developed all manner of coping strategies, for example sleeping in two shifts every day. 
 
So what do you do now?  
 
You live with it, or you go for diagnosis and maybe treatment.  I want to talk a bit about these options, but first:  The Sleep Log.

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Next post:  xxiii. We interrupt this program…

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