Circadian rhythm sleep disorders (CRSD) are a family of sleep disorders affecting (among other bodily processes) the timing of sleep. People with circadian rhythm sleep disorders are unable to go to sleep and awaken at the times commonly required for work and school as well as social needs. They are generally able to get enough sleep if allowed to sleep and wake at the times dictated by their “body clocks”. The quality of their sleep is usually normal unless they also have another sleep disorder.
Humans, like most living organisms, have various biological rhythms. Circadian rhythms, often referred to as the body clock or the biological clock, control processes that re-occur daily, e.g. body temperature, alertness, and hormone secretion as well as sleep timing. Due to the circadian clock, sleepiness does not continuously increase throughout the day; a person’s desire and ability to fall asleep is influenced both by the length of time since the person woke from an adequate sleep and by internal circadian rhythms. Thus, a person’s body is ready for sleep and for wakefulness at relatively specific times of the day.
Sleep researcher Yaron Dagan 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”.
One of these disorders is extrinsic (from Latin extrinsecus, from without, on the outside) or circumstantial:
- Shift work sleep disorder, which affects people who work nights or rotating shifts.
Formerly, jet lag, too, was classified as an extrinsic type circadian rhythm disorder.
Four of them are intrinsic (from Latin intrinsecus, on the inside, inwardly), “built-in”:
- Advanced sleep phase disorder (ASPD), a.k.a. advanced sleep phase syndrome (ASPS), characterized by difficulty staying awake in the evening and difficulty staying asleep in the morning
- Delayed sleep phase disorder (DSPD), a.k.a. 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
- 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
- Non-24-hour sleep–wake disorder (non-24, a.k.a. hypernychthemeral syndrome), 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.
Normal circadian rhythms
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 late at night 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.
Circadian rhythm abnormalities
Non-24-hour sleep–wake disorder 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 DSPD (Delayed sleep phase disorder), 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.”
Circadian rhythm abnormalities are also extremely commonly co-morbid with ADHD, especially in the form of sleep initiation insomnia. These have been genetically linked by findings of polymorphism in genes in common between those apparently involved in ADHD and those involved in the circadian rhythm and a high proportion of DSPD among those with ADHD, however no specific or further cause-effect relationship has been proven.
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.
Possible treatments for circadian rhythm sleep disorders include:
- Behavior therapy or advice about sleep hygiene 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.
- Dark therapy, for example the use of blue-blocking goggles, is used to block blue- and bluegreen wavelength light from reaching the eye during evening hours so that the production of melatonin is not decreased or eliminated.
- Medications such as melatonin and modafinil (Provigil), or other short term sleep aids or wake-promoting agents can be beneficial; the former is a natural neurohormone responsible partly and in tiny amounts for the human body clock. The melatonin agonist Tasimelteon, trade name Hetlioz, has been approved in the USA solely for the treatment of non-24-hour sleep–wake disorder in totally blind people.
- Sleep phase chronotherapy may progressively advance or delay sleep time.
- 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. Retrieved 2010-10-13.
- “Highlights of Changes from DSM-IV-TR to DSM-5” (PDF). American Psychiatric Association. May 17, 2013. Archived from the original (PDF) on February 26, 2015. Retrieved May 23, 2013.
- National Institutes of Health. “Sleep – Information about Sleep”. Retrieved 2007-01-28.
- Cataletto, Mary E.; Hertz, Gila (2005-09-07). “Sleeplessness and Circadian Rhythm Disorder” (Free registration required). eMedicine from WebMD. Retrieved 2008-07-20.
- Kissling Christian (2008). “A polymorphism at the 3′-untranslated region of theCLOCK gene is associated with adult attention-deficit hyperactivity disorder”. American Journal of Medical Genetics Part B. 147B (3): 333–338. doi:10.1002/ajmg.b.30602.
- “Adult attention-deficit hyperactivity disorder is associated with alterations in circadian rhythms at the behavioural, endocrine and molecular levels” – Molecular Psychiatry, (22 November 2011) doi:10.1038/mp.2011.149 (PubMed ID: 22105622 pre pub)
- Van der Heijden KB, Smits MG, Van Someren EJ, Gunning WB (2005). “Idiopathic chronic sleep onset insomnia in attention-deficit/hyperactivity disorder: a circadian rhythm sleep disorder”. Chronobiology International. 22 (3): 559–70. doi:10.1081/CBI-200062410. PMID 16076654.
- – “About three-fourths of all adults with ADHD report inability to ‘shut off my mind so I can fall asleep at night’.”
- First, Michael B. (2005). “New Diagnostic Codes for Sleep Disorders”. American Psychiatric Association. Retrieved 2008-08-08.
- “Sleep Hygiene” (PDF). Sleep Disorders Australia. 2006. p. 1. Archived from the original (PDF) on 2011-10-04. Retrieved 2011-12-09.
- http://www.health.harvard.edu/newsletters/Harvard_Health_Letter/2012/May/blue-light-has-a-dark-side/ “Blue light has a dark side” online article from the May 2012 edition of Harvard Health Letter
- Food and Drug Administration (January 31, 2014). “FDA approves Hetlioz: first treatment for non-24 hour sleep-wake disorder”. FDA.
- Circadian Sleep Disorders Network
- 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
- Infographic on circadian sleep disorders