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Delayed Sleep Phase Disorder: Prevalence, Diagnostic aspects, Associated factors and Treatment concepts
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Psychiatry, University Hospital.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Delayed sleep phase disorder (DSPD) is the most common circadian rhythm sleep disorder. Persons with DSPD have great difficulties falling asleep and waking up at conventional times. To diagnose DSPD this delayed sleep-wake rhythm should cause social impairment and distress for the individual. Evening melatonin and morning bright light are the recommended treatments. The overall aim of this thesis was to evaluate at-home treatment with Light therapy (LT) and the feasibility of adding cognitive behavior therapy (CBT) to LT in DSPD, furthermore prevalence, diagnostic aspects and associated factors were investigated.

Study I included 673 randomly selected individuals aged 16–26 years. The prevalence of DSPD was 4.0%. Unemployment (defined as an absence of educational or work activities) and an elevated level of anxiety were associated with DSPD.

In study II, dim light melatonin onset (DLMO) was measured in healthy adults. Time for DLMO DLMO (Mean±SD) was 20:58±55 minutes.

Studies III, IV, and V present results from a randomized controlled trial examining the feasibility of CBT as an additive treatment to LT with scheduled rise times, in persons with DSPD. Sleep onset and sleep offset was significantly advanced from baseline (03:00±1:20; 10:22±2:02 respectively) to the end of LT (01:27±1:41; 08:05±1:29, p<0.001 respectively). This advancement was predicted by consistent daily usage of the LT-lamp. At the follow-ups after LT and CBT or LT alone, sleep onset remained stable, sleep offset was delayed, and sleep difficulties were further improved, but there was no significant group interaction over time. There was a significant group interaction over time in the severity of anxiety and depressive symptoms, both in favor of the LT+CBT group.

Conclusively, DSPD was common among adolescents and young adults and it was associated with unemployment and elevated levels of anxiety. DLMO appeared in the expected time range in healthy working adults. At-home treatment with LT with scheduled rise times advanced sleep-wake rhythm and improved sleep difficulties in DSPD. Even though sleep-wake rhythm was not further advanced or better preserved in the participants that received LT+CBT compared to LT alone, the addition of CBT to the treatment regimen was feasible and well accepted.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2016. , p. 70
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1243
Keywords [en]
delayed sleep phase disorder, prevalence, diagnostic aspects, associated factors, light therapy and cognitive behavior therapy
National Category
Neurosciences
Identifiers
URN: urn:nbn:se:uu:diva-299887ISBN: 978-91-554-9645-6 (print)OAI: oai:DiVA.org:uu-299887DiVA, id: diva2:951793
Public defence
2016-09-29, Gunnesalen, Akademiska sjukhuset ingång 10, Uppsala, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2016-09-07 Created: 2016-07-29 Last updated: 2018-01-10
List of papers
1. Delayed sleep phase disorder in a Swedish cohort of adolescents and young adults: Prevalence and associated factors
Open this publication in new window or tab >>Delayed sleep phase disorder in a Swedish cohort of adolescents and young adults: Prevalence and associated factors
Show others...
2016 (English)In: Chronobiology International, ISSN 0742-0528, E-ISSN 1525-6073, Vol. 33, no 10, p. 1331-1339Article in journal (Refereed) Published
Abstract [en]

A delayed sleep-wake and circadian rhythm often occurs during puberty. While some individuals only develop a delayed sleep phase (DSP), others will fulfill the criteria for the diagnosis of delayed sleep phase disorder (DSPD). All previous studies have however not separated DSP from DSPD, and, as a result, the prevalence and associated factors are largely unknown for the two conditions individually. We estimated the prevalence of DSP and DSPD in a Swedish cohort of adolescents and young adults. We also investigated associated factors in the two conditions relative to each other and individuals with no delayed sleep phase. A questionnaire regarding sleep patterns, demographics, substance use/abuse, and symptoms of depression, anxiety, worry, and rumination was sent to 1000 randomly selected participants (16–26 years of age) in Uppsala, Sweden (response rate = 68%). DSP was defined as a late sleep onset and a preferred late wake up time. The DSPD diagnosis was further operationalized according to the Diagnostic and Statistical Manual of Mental Disorders, Edition 5 (DSM-5) criteria including insomnia or excessive sleepiness, distress or dysfunction caused by the delayed sleep phase and that the sleep problem had been evident for 3 months. DSP occurred at a frequency of 4.6% and DSPD at a frequency of 4% in the investigated cohort. DSP was more common in males and was associated with not attending educational activity or work, having shift work, nicotine and alcohol use and less rumination. DSPD was equally common in males and females and was associated with not attending educational activity or work and with elevated levels of anxiety. Both DSP and DSPD appear to be common in adolescents and young adults in this Swedish cohort. No educational activity or work was associated with both DSP and DSPD. However, there were also apparent differences between the two groups in shift work, substance use and mental health, relative to persons with no delayed sleep phase. Thus, it seems reasonable to assess DSP and DSPD as distinct entities in future studies.

Keywords
delayed sleep phase, delayed sleep phase disorder, associated factors, occupational status, shift work, substance use/abuse.
National Category
Neurosciences
Identifiers
urn:nbn:se:uu:diva-298762 (URN)10.1080/07420528.2016.1217002 (DOI)000388746800003 ()27537980 (PubMedID)
Available from: 2016-07-28 Created: 2016-07-07 Last updated: 2018-01-10Bibliographically approved
2. Dim light melatonin onset in normal adults and its relationship with sleep timing and diurnal preference
Open this publication in new window or tab >>Dim light melatonin onset in normal adults and its relationship with sleep timing and diurnal preference
2012 (English)In: Biological rhythm research, ISSN 0929-1016, E-ISSN 1744-4179, Vol. 43, no 5, p. 497-503Article in journal (Refereed) Published
Abstract [en]

Dim light melatonin onset (DLMO) is defined as the start of the melatonin production in the evening during dim light conditions and has become a reliable phase marker of the circadian clock. The aim of the study was to investigate DLMO and its association with sleep timing and diurnal preferences in healthy working adults during real-life conditions. Fourteen adults were investigated. A sleep diary was kept during the preceding week, but no fixed sleep–wake schedule was implemented. Diurnal preferences were measured with the Horne–O¨ stberg Morningness–Eveningness Questionnaire. DLMO was defined as the time point when melatonin in saliva exceeded a threshold of 3 ng/L. Results showed that DLMO appeared in the expected time interval but was not significantly associated with sleep timing or diurnal preference. The results illustrate the complexity of monitoring sleep patterns in real-life settings.

National Category
Psychiatry
Identifiers
urn:nbn:se:uu:diva-158778 (URN)10.1080/09291016.2011.605631 (DOI)000308443900004 ()
Available from: 2011-09-14 Created: 2011-09-14 Last updated: 2017-12-08Bibliographically approved
3. Cognitive behavioral therapy as an adjunct treatment to light therapy for delayed sleep phase disorder in young adults.: A randomized controlled feasibility study
Open this publication in new window or tab >>Cognitive behavioral therapy as an adjunct treatment to light therapy for delayed sleep phase disorder in young adults.: A randomized controlled feasibility study
2016 (English)In: Behavioural Sleep Medicine, ISSN 1540-2002, E-ISSN 1540-2010, Vol. 14, no 2, p. 212-232Article in journal (Refereed) Published
Abstract [en]

Delayed sleep phase disorder (DSPD) is common among young people, but there is still no evidence-based treatment available. In the present study, the feasibility of cognitive behavioral therapy (CBT) was evaluated as an additive treatment to light therapy (LT) in DSPD. A randomized controlled trial with participants aged 16 to 26 years received LT for two weeks followed by either four weeks of CBT or no treatment (NT). LT advanced sleep-wake rhythm in both groups. Comparing LT+CBT with LT+NT, no significant group differences were observed in the primary endpoints. Although anxiety and depression scores were low at pretreatment, they decreased significantly more in LT+CBT compared to LT+NT. The results are discussed and some suggestions are given for further studies.

Place, publisher, year, edition, pages
Taylor & Francis, 2016
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:uu:diva-233847 (URN)10.1080/15402002.2014.981817 (DOI)000371594800008 ()
Available from: 2014-10-10 Created: 2014-10-10 Last updated: 2017-12-05Bibliographically approved
4. Developing a cognitive behavioral therapy manual for delayed sleep wake phase disorder
Open this publication in new window or tab >>Developing a cognitive behavioral therapy manual for delayed sleep wake phase disorder
2016 (English)In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 45, no 6, p. 518-532Article in journal (Refereed) Published
Abstract [en]

This article reports the development of a treatment protocol, based on cognitive behavioral therapy (CBT) principles, for delayed sleep–wake phase disorder (DSWPD). The protocol consists of psycho-education, presenting a CBT model for DSWPD, case formulation, motivational interviewing, registering sleep in a diary, strategies to improve the rhythm of sleep and wakefulness, relaxation training, cognitive restructuring, strategies to cope with daytime symptoms, constructing an individualized CBT program, and learning how to deal with relapses. Qualitative data, focusing on how the patients perceived the protocol, were collected within the realm of a trial exploring the efficacy of the protocol. These findings highlighted several advantages but also disadvantages of the therapy. It is our hope that this paper might act as a platform for further clinical work and future research efforts in patients with DSWPD.

Place, publisher, year, edition, pages
Taylor & Francis Group, 2016
National Category
Neurosciences
Identifiers
urn:nbn:se:uu:diva-298761 (URN)10.1080/16506073.2016.1207096 (DOI)000389240600009 ()
Available from: 2016-07-07 Created: 2016-07-07 Last updated: 2018-01-10Bibliographically approved
5. Light therapy with scheduled rise times in young adults with delayed sleep phase disorder: Therapeutic outcomes and possible predictors
Open this publication in new window or tab >>Light therapy with scheduled rise times in young adults with delayed sleep phase disorder: Therapeutic outcomes and possible predictors
2018 (English)In: Behavioural Sleep Medicine, ISSN 1540-2002, E-ISSN 1540-2010, Vol. 16, no 4, p. 325-336Article in journal (Refereed) Published
Abstract [en]

Clinical trials with light therapy (LT) for delayed sleep phase disorder (DSPD) are sparse and little is known about factors that are favorable for improvements. In this study, LT with scheduled rise times was conducted at home for 14 days by 44 participants with DSPD aged 16–26 years. Primary outcomes were sleep onset and sleep offset. Potential predictors were demographic characteristics, chronotype, dim light melatonin onset, the number of days the LT lamp was used, the daily duration of LT, daytime sleepiness, anxiety, depression, worry, and rumination. Significant advances were observed in sleep onset and sleep offset from baseline to the end of treatment. The number of days of LT predicted earlier sleep onset and sleep offset.

Place, publisher, year, edition, pages
Taylor & Francis Group, 2018
National Category
Neurosciences Neurology
Identifiers
urn:nbn:se:uu:diva-298760 (URN)10.1080/15402002.2016.1210150 (DOI)000431524200002 ()27712107 (PubMedID)
Available from: 2016-07-07 Created: 2016-07-07 Last updated: 2018-07-04Bibliographically approved

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