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Delayed Sleep Phase Syndrome: A Chronobiological Disorder With Sleep-Onset Insomnia

Delayed Sleep Phase Syndrome: A Chronobiological Disorder With Sleep-Onset Insomnia Abstract • We describe a new syndrome called "delayed sleep phase insomnia." Thirty of 450 patients seen for a primary insomniac complaint had the following characteristics: (1) chronic inability to fall asleep at a desired clock time; (2) when not on a strict schedule, the patients have a normal sleep pattern and after a sleep of normal length awaken spontaneously and feel refreshed; and (3) a long history of unsuccessful attempts to treat the problem. These patients were younger than the general insomniac population and as a group did not have a specific psychiatric disorder. Six patients' histories are described in detail, including the successful nonpharmacological chronotherapy regimen (resetting the patients' biological clock by progressive phase delay). Delayed sleep phase insomnia is proposed to be a disorder of the circadian sleep-wake rhythm in which the "advance" portion of the phase response curve is small. References 1. Cooper JR (ed): Sedative-Hypnotic Drugs: Risks and Benefits . Rockville, Md, National Institute on Drug Abuse, 1977. 2. Hammond EC: Some preliminary findings on physical complaints from a prospective study of 1,064,004 men and women . Am J Public Health 1964;54:11-23.Crossref 3. Karacan I, Thornby JT, Anch M, et al: Prevalence of sleep disturbance in a primarily urban Florida county . Soc Sci Med 1976;10:239-244.Crossref 4. Kripke DF, Simons RN, Garfinkel L, et al: Short and long sleep and sleeping pills: Is increased mortality associated? Arch Gen Psychiatry 1979;36:103-116.Crossref 5. Sleeping Pills, Insomnia, and Medical Practice: A Study by the Institute of Medicine, publication IOM-79-04. National Academy of Sciences, 1979. 6. Dement W, Guilleminault C, Zarcone V: The pathologies of sleep: A case series approach , in Tower DB (ed): The Nervous System . New York, Raven Press, vol 2, 1975, pp 501-518. 7. Balter MB, Bauer ML: Patterns of prescribing and use of hypnotic drugs in the United States , in Clift AD (ed): Sleep Disturbance and Hypnotic Drug Dependence . Amsterdam, Excerpta Medica, 1975, pp 261-293. 8. Coursey R, Frankel B, Gaarder K: EMG biofeedback and autogenic training as relaxation technique for chronic sleep-onset insomnia . Biofeedback Self Regul 1976;1:353-354. 9. Davison GC, Tusjimoto RN, Glaros A: Attribution and the maintenance of behavior change in falling asleep . J Abnorm Psychol 1973;82:124-133.Crossref 10. Freedman R, Papsdorf JD: Biofeedback and progressive relaxation treatment of sleep-onset insomnia: A controlled all night investigation . Biofeedback Self Regul 1976;1:253-271.Crossref 11. Hyland HH: Disturbances of sleep and their treatment . Med Clin North Am 1952;36:539-555. 12. Jacobson E: Progressive Relaxation . Chicago, University of Chicago Press, 1938. 13. Kahn M, Baker BL, Weiss JM: Treatment of insomnia by relaxation training . J Abnorm Psychol 1968;73:556-558.Crossref 14. Nicassio P, Bootzin R: A comparison of progressive relaxation and autogenic training as treatments for insomnia . J Abnorm Psychol 1974;83:253-260.Crossref 15. Kupfer DJ, Foster FG, Reich L, et al: EEG sleep changes as predictors in depression . Am J Psychiatry 1976;133:622-626. 16. Dement W, Guilleminault C (eds): Diagnostic classification of sleep and arousal disorders . Sleep 1979;2:1-154. 17. Kales A, Bixler E, Tan TL, et al: Chronic hypnotic-drug use: Ineffectiveness, drug withdrawal insomnia, and dependence . JAMA 1974;227:513-517.Crossref 18. Guilleminault C, Dement WC (eds): Sleep Apnea Syndromes . New York, Alan R Liss Inc, 1978. 19. Kupfer DJ: REM latency: A psychobiologic marker for primary depressive disease . Biol Psychiatry 1976;11:159-174. 20. Hauri P: A case series analysis of 141 consecutive insomniacs evaluated at the Dartmouth Sleep Lab, abstracted . Sleep Res 1976;5:173. 21. Weitzman ED, Pollak CP: Disorder of the circadian sleep-wake cycle . Med Times 1979;107:83-94. 22. Czeisler CA, Richardson GS, Coleman R, et al: Chronotherapy: Resetting the circadian clock of patients with delayed sleep phase insomnia . Sleep 1981;4:1-21. 23. Horne JA, Üstberg O: A self-assessment questionnaire to determine morningness-eveningness in human circadian rhythms . Int J Chronobiol 1976;4:97-110. 24. Haider I: Patterns of insomnia in depressive illness—A subjective evaluation . Br J Psychiatry 1968;114:1127-1132.Crossref 25. Johns M, Gay T, Goodyear M, et al: Sleep habits of healthy young adults: Use of a sleep questionnaire . Br J Prevent Soc Med 1971;25:236-241. 26. Roth T, Kramer M: The nature of insomnia: A descriptive summary of sleep clinic population, abstracted . Sleep Res 1975;4:234. 27. Schneider D, Gnirss R: Psychosomatische insomnie . Schweiz Arch Neurol Neurochir Psychiatr 1977;120:131-151. 28. Sweetwood HL, Kripke DF, Grant I, et al: Sleep disorder and psychobiological symptomatology in male psychiatric out-patients and male non-patients . Psychosom Med 1976;38:373-378.Crossref 29. Stonehill E: Insomnia in psychiatric illness . Postgrad Med J 1976;52:19-25.Crossref 30. Tune GS: The influence of age and temperament on the adult human sleep-wakefulness pattern . Br J Psychol 1969;60:431-441.Crossref 31. Ushely VA: Oedipal jealousy and passive dependency states in insomnia . J Clin Psychopathol 1950;11:65-69. 32. Wexberg LE: Insomnia as related to anxiety and ambition . J Clin Psychopathol 1949;10:373-375. 33. Costello CG, Selby MM: The relationships between sleep patterns and reactive and endogenous depression . Br J Psychiatry 1965;111:497-501.Crossref 34. Noelle E, Neumann EP: Jahrbuch der Offentlichen Meinung . Allensbach am Bodensee, Germany, Verlag für Demoskopie, 1957. 35. Carskadon M, Dement W, Mitler W, et al: Self report versus sleep laboratory findings in 122 drug-free subjects with the complaint of chronic insomnia . Am J Psychiatry 1976;133:1382-1388. 36. Weitzman ED, Czeisler CA, Spielman AJ, et al: Chronotherapy treatment of a patient with a combined chronic short sleep period and delayed sleep phase syndrome, abstracted . Sleep Res 1980;9:232. 37. Kokkoris CP, Weitzman ED, Pollak CP: Long-term ambulatory temperature monitoring in a subject with a hypernychthemeral sleep-wake cycle disturbance , Sleep 1978;1:177-190. 38. Wever R: The Circadian System of Man . New York, Springer-Verlag Inc, 1979. 39. Weitzman ED, Czeisler CA, Moore-Ede M: Sleep-wake, neuroendocrine and body temperature circadian rhythms under entrained and nonentrained (free running) conditions in man , in Suda M, Hayaishi O, Nakagawa H (eds): Biological Rhythms and Their Central Mechanisms . New York, Elsevier North Holland Inc, 1979, pp 199-227. 40. Czeisler CA: Human Circadian Physiology: Internal Organization of Temperature, Sleep-Wake and Neuroendocrine Function in an Environment Free of Time Cues, thesis. Stanford University, Stanford, Calif, 1978. 41. Czeisler CA, Weitzman ED, Moore-Ede MC, et al: Human sleep: Its duration and organization depend on its circadian phase . Science 1980;210:1264-1267.Crossref 42. Kiloh LG, Andrews G, Neilson M, et al: The relationship of the syndromes called endogenous and neurotic depression . Br J Psychiatry 1972;121:183-196.Crossref 43. Weiss HR, Kasinoff BH, Bailey MA: An exploration of reported sleep disturbances . J Nerv Ment Dis 1962;134:528-534.Crossref 44. Kiloh LG, Garside RF: The independence of neurotic depression and endogenous depression . Br J Psychiatry 1963;109:451-463.Crossref 45. Conn JH: Psychogenesis and psychotherapy of insomnia . J Clin Psychopathol 1950;11:85-91. 46. Bunning E: The Physiological Clock , ed 3. New York, Springer-Verlag Inc, 1973. 47. Aschoff J, Hoffman K, Pohl H, et al: Re-entrainment of circadian rhythms after phase-shifts of the zeitgeber . Chronobiologia 1975;2:23-78. 48. Klein KE, Hermann H, Kuklinski P, et al: Circadian performance rhythms: Experimental studies in air operation , in Mackie RR (ed): Vigilance: Theory, Operational Performance and Physiological Correlates . New York, Plenum Press Inc, 1977, pp 117-132. 49. Weitzman ED: Sleep and its disorders , in Cowan M (ed): Annual Review of Neuroscience . Palo Alto, Calif, Annual Reviews Inc, 1981, vol 4, pp 381-471. 50. Wehr T, Wirz-Justice A, Goodwin RK, et al: Phase advance of the circadian sleep-wake cycle as an anti-depressant . Science 1979;206:710-711.Crossref 51. Rudolf GAE, Schilgen B, Tolle R: Anti-depressive behandlung mittels schlafentzug . Nervenarzt 1977;48:1-11. 52. Vogel GW, Thurmond A, Gibbons P, et al: REM sleep reduction effects on depression syndromes . Arch Gen Psychiatry 1975;32:765-777.Crossref 53. Weitzman E: Sleep and aging , in Katzman R, Terry R (eds): Neurology of Aging . Philadelphia, FA Davis Co, to be published. 54. Weitzman ED, Pollak CP, McGregor P: The polysomnographic evaluation of sleep disorders in man , in Aminoff MJ (ed): Electrophysiological Approaches to Neurological Diagnosis . New York, Churchill Livingstone, 1980, pp 496-524. 55. Weitzman ED, Czeisler CA, Zimmerman JC, et al: Biological rhythms in man: Relationship of sleep-wake, cortisol, growth hormone and temperature during temporal isolation , in Martin JB, Reichlin S, Bick K (eds): Neurosecretion and Brain Peptides . New York, Raven Press, 1981, pp 475-496. 56. Weitzman ED, Czeisler CA, Zimmerman JC, et al: Chronobiological disorders: Analytic and therapeutic techniques , in Guilleminault C (ed): Disorders of Sleeping and Waking: Indications and Techniques . Reading, Mass, Addison-Wesley Publishing Co Inc, to be published. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of General Psychiatry American Medical Association

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Publisher
American Medical Association
Copyright
Copyright © 1981 American Medical Association. All Rights Reserved.
ISSN
0003-990X
eISSN
1598-3636
DOI
10.1001/archpsyc.1981.01780320017001
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Abstract

Abstract • We describe a new syndrome called "delayed sleep phase insomnia." Thirty of 450 patients seen for a primary insomniac complaint had the following characteristics: (1) chronic inability to fall asleep at a desired clock time; (2) when not on a strict schedule, the patients have a normal sleep pattern and after a sleep of normal length awaken spontaneously and feel refreshed; and (3) a long history of unsuccessful attempts to treat the problem. These patients were younger than the general insomniac population and as a group did not have a specific psychiatric disorder. Six patients' histories are described in detail, including the successful nonpharmacological chronotherapy regimen (resetting the patients' biological clock by progressive phase delay). Delayed sleep phase insomnia is proposed to be a disorder of the circadian sleep-wake rhythm in which the "advance" portion of the phase response curve is small. References 1. Cooper JR (ed): Sedative-Hypnotic Drugs: Risks and Benefits . Rockville, Md, National Institute on Drug Abuse, 1977. 2. Hammond EC: Some preliminary findings on physical complaints from a prospective study of 1,064,004 men and women . Am J Public Health 1964;54:11-23.Crossref 3. Karacan I, Thornby JT, Anch M, et al: Prevalence of sleep disturbance in a primarily urban Florida county . Soc Sci Med 1976;10:239-244.Crossref 4. Kripke DF, Simons RN, Garfinkel L, et al: Short and long sleep and sleeping pills: Is increased mortality associated? Arch Gen Psychiatry 1979;36:103-116.Crossref 5. Sleeping Pills, Insomnia, and Medical Practice: A Study by the Institute of Medicine, publication IOM-79-04. National Academy of Sciences, 1979. 6. Dement W, Guilleminault C, Zarcone V: The pathologies of sleep: A case series approach , in Tower DB (ed): The Nervous System . New York, Raven Press, vol 2, 1975, pp 501-518. 7. Balter MB, Bauer ML: Patterns of prescribing and use of hypnotic drugs in the United States , in Clift AD (ed): Sleep Disturbance and Hypnotic Drug Dependence . Amsterdam, Excerpta Medica, 1975, pp 261-293. 8. Coursey R, Frankel B, Gaarder K: EMG biofeedback and autogenic training as relaxation technique for chronic sleep-onset insomnia . Biofeedback Self Regul 1976;1:353-354. 9. Davison GC, Tusjimoto RN, Glaros A: Attribution and the maintenance of behavior change in falling asleep . J Abnorm Psychol 1973;82:124-133.Crossref 10. Freedman R, Papsdorf JD: Biofeedback and progressive relaxation treatment of sleep-onset insomnia: A controlled all night investigation . Biofeedback Self Regul 1976;1:253-271.Crossref 11. Hyland HH: Disturbances of sleep and their treatment . Med Clin North Am 1952;36:539-555. 12. Jacobson E: Progressive Relaxation . Chicago, University of Chicago Press, 1938. 13. Kahn M, Baker BL, Weiss JM: Treatment of insomnia by relaxation training . J Abnorm Psychol 1968;73:556-558.Crossref 14. Nicassio P, Bootzin R: A comparison of progressive relaxation and autogenic training as treatments for insomnia . J Abnorm Psychol 1974;83:253-260.Crossref 15. Kupfer DJ, Foster FG, Reich L, et al: EEG sleep changes as predictors in depression . Am J Psychiatry 1976;133:622-626. 16. Dement W, Guilleminault C (eds): Diagnostic classification of sleep and arousal disorders . Sleep 1979;2:1-154. 17. Kales A, Bixler E, Tan TL, et al: Chronic hypnotic-drug use: Ineffectiveness, drug withdrawal insomnia, and dependence . JAMA 1974;227:513-517.Crossref 18. Guilleminault C, Dement WC (eds): Sleep Apnea Syndromes . New York, Alan R Liss Inc, 1978. 19. Kupfer DJ: REM latency: A psychobiologic marker for primary depressive disease . Biol Psychiatry 1976;11:159-174. 20. Hauri P: A case series analysis of 141 consecutive insomniacs evaluated at the Dartmouth Sleep Lab, abstracted . Sleep Res 1976;5:173. 21. Weitzman ED, Pollak CP: Disorder of the circadian sleep-wake cycle . Med Times 1979;107:83-94. 22. Czeisler CA, Richardson GS, Coleman R, et al: Chronotherapy: Resetting the circadian clock of patients with delayed sleep phase insomnia . Sleep 1981;4:1-21. 23. Horne JA, Üstberg O: A self-assessment questionnaire to determine morningness-eveningness in human circadian rhythms . Int J Chronobiol 1976;4:97-110. 24. Haider I: Patterns of insomnia in depressive illness—A subjective evaluation . Br J Psychiatry 1968;114:1127-1132.Crossref 25. Johns M, Gay T, Goodyear M, et al: Sleep habits of healthy young adults: Use of a sleep questionnaire . Br J Prevent Soc Med 1971;25:236-241. 26. Roth T, Kramer M: The nature of insomnia: A descriptive summary of sleep clinic population, abstracted . Sleep Res 1975;4:234. 27. Schneider D, Gnirss R: Psychosomatische insomnie . Schweiz Arch Neurol Neurochir Psychiatr 1977;120:131-151. 28. Sweetwood HL, Kripke DF, Grant I, et al: Sleep disorder and psychobiological symptomatology in male psychiatric out-patients and male non-patients . Psychosom Med 1976;38:373-378.Crossref 29. Stonehill E: Insomnia in psychiatric illness . Postgrad Med J 1976;52:19-25.Crossref 30. Tune GS: The influence of age and temperament on the adult human sleep-wakefulness pattern . Br J Psychol 1969;60:431-441.Crossref 31. Ushely VA: Oedipal jealousy and passive dependency states in insomnia . J Clin Psychopathol 1950;11:65-69. 32. Wexberg LE: Insomnia as related to anxiety and ambition . J Clin Psychopathol 1949;10:373-375. 33. Costello CG, Selby MM: The relationships between sleep patterns and reactive and endogenous depression . Br J Psychiatry 1965;111:497-501.Crossref 34. Noelle E, Neumann EP: Jahrbuch der Offentlichen Meinung . Allensbach am Bodensee, Germany, Verlag für Demoskopie, 1957. 35. Carskadon M, Dement W, Mitler W, et al: Self report versus sleep laboratory findings in 122 drug-free subjects with the complaint of chronic insomnia . Am J Psychiatry 1976;133:1382-1388. 36. Weitzman ED, Czeisler CA, Spielman AJ, et al: Chronotherapy treatment of a patient with a combined chronic short sleep period and delayed sleep phase syndrome, abstracted . Sleep Res 1980;9:232. 37. Kokkoris CP, Weitzman ED, Pollak CP: Long-term ambulatory temperature monitoring in a subject with a hypernychthemeral sleep-wake cycle disturbance , Sleep 1978;1:177-190. 38. Wever R: The Circadian System of Man . New York, Springer-Verlag Inc, 1979. 39. Weitzman ED, Czeisler CA, Moore-Ede M: Sleep-wake, neuroendocrine and body temperature circadian rhythms under entrained and nonentrained (free running) conditions in man , in Suda M, Hayaishi O, Nakagawa H (eds): Biological Rhythms and Their Central Mechanisms . New York, Elsevier North Holland Inc, 1979, pp 199-227. 40. Czeisler CA: Human Circadian Physiology: Internal Organization of Temperature, Sleep-Wake and Neuroendocrine Function in an Environment Free of Time Cues, thesis. Stanford University, Stanford, Calif, 1978. 41. Czeisler CA, Weitzman ED, Moore-Ede MC, et al: Human sleep: Its duration and organization depend on its circadian phase . Science 1980;210:1264-1267.Crossref 42. Kiloh LG, Andrews G, Neilson M, et al: The relationship of the syndromes called endogenous and neurotic depression . Br J Psychiatry 1972;121:183-196.Crossref 43. Weiss HR, Kasinoff BH, Bailey MA: An exploration of reported sleep disturbances . J Nerv Ment Dis 1962;134:528-534.Crossref 44. Kiloh LG, Garside RF: The independence of neurotic depression and endogenous depression . Br J Psychiatry 1963;109:451-463.Crossref 45. Conn JH: Psychogenesis and psychotherapy of insomnia . J Clin Psychopathol 1950;11:85-91. 46. Bunning E: The Physiological Clock , ed 3. New York, Springer-Verlag Inc, 1973. 47. Aschoff J, Hoffman K, Pohl H, et al: Re-entrainment of circadian rhythms after phase-shifts of the zeitgeber . Chronobiologia 1975;2:23-78. 48. Klein KE, Hermann H, Kuklinski P, et al: Circadian performance rhythms: Experimental studies in air operation , in Mackie RR (ed): Vigilance: Theory, Operational Performance and Physiological Correlates . New York, Plenum Press Inc, 1977, pp 117-132. 49. Weitzman ED: Sleep and its disorders , in Cowan M (ed): Annual Review of Neuroscience . Palo Alto, Calif, Annual Reviews Inc, 1981, vol 4, pp 381-471. 50. Wehr T, Wirz-Justice A, Goodwin RK, et al: Phase advance of the circadian sleep-wake cycle as an anti-depressant . Science 1979;206:710-711.Crossref 51. Rudolf GAE, Schilgen B, Tolle R: Anti-depressive behandlung mittels schlafentzug . Nervenarzt 1977;48:1-11. 52. Vogel GW, Thurmond A, Gibbons P, et al: REM sleep reduction effects on depression syndromes . Arch Gen Psychiatry 1975;32:765-777.Crossref 53. Weitzman E: Sleep and aging , in Katzman R, Terry R (eds): Neurology of Aging . Philadelphia, FA Davis Co, to be published. 54. Weitzman ED, Pollak CP, McGregor P: The polysomnographic evaluation of sleep disorders in man , in Aminoff MJ (ed): Electrophysiological Approaches to Neurological Diagnosis . New York, Churchill Livingstone, 1980, pp 496-524. 55. Weitzman ED, Czeisler CA, Zimmerman JC, et al: Biological rhythms in man: Relationship of sleep-wake, cortisol, growth hormone and temperature during temporal isolation , in Martin JB, Reichlin S, Bick K (eds): Neurosecretion and Brain Peptides . New York, Raven Press, 1981, pp 475-496. 56. Weitzman ED, Czeisler CA, Zimmerman JC, et al: Chronobiological disorders: Analytic and therapeutic techniques , in Guilleminault C (ed): Disorders of Sleeping and Waking: Indications and Techniques . Reading, Mass, Addison-Wesley Publishing Co Inc, to be published.

Journal

Archives of General PsychiatryAmerican Medical Association

Published: Jul 1, 1981

References