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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. , 70 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1243
Keyword [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: 978-91-554-9645-6OAI: oai:DiVA.org:uu-299887DiVA: 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: 2016-09-13
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
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2016 (English)In: Chronobiology International, ISSN 0742-0528, E-ISSN 1525-6073Article in journal (Refereed) Epub ahead of print
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.

Place, publisher, year, edition, pages
Taylor & Francis Group, 2016
Keyword
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)
External cooperation:
Available from: 2016-07-28 Created: 2016-07-07 Last updated: 2016-09-02Bibliographically 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, Vol. 43, no 5, 497-503 p.Article 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: 2016-09-02Bibliographically 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, 212-232 p.Article 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: 2016-09-02Bibliographically approved
4. Developing a cognitive behavioral therapy manual for delayed sleep wake phase disorder: CBT for DSWPD - A treatment manual
Open this publication in new window or tab >>Developing a cognitive behavioral therapy manual for delayed sleep wake phase disorder: CBT for DSWPD - A treatment manual
2016 (English)In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 45, no 6, 518-532 p.Article 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)
Available from: 2016-07-07 Created: 2016-07-07 Last updated: 2016-09-02Bibliographically 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
2016 (English)In: Behavioural Sleep Medicine, ISSN 1540-2002, E-ISSN 1540-2010Article in journal (Refereed) Epub ahead of print
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.

During puberty, there is a known delay in sleep–wake preference and circadian rhythm (Carskadon, Acebo, & Jenni, 2004Carskadon, M. A., Acebo, C., & Jenni, O. G. (2004). Regulation of adolescent sleep: Implications for behavior. Annals of the New York Academy of Sciences, 1021, 276–291.; Carskadon, Vieira, & Acebo, 1993 Carskadon, M. A., Vieira, C., & Acebo, C. (1993). Association between puberty and delayed phase preference. Sleep, 16, 258–262.). If this delay becomes persistent and causes a functional impairment, the person has developed delayed sleep phase disorder (DSPD). DSPD is most common among adolescents and young adults, and the prevalence is about 1–10% in this group (American Academy of Sleep Medicine, 2014 American Academy of Sleep Medicine. (2014). International classification of sleep disorders. Diagnostic and coding manual (3d ed.). Westchester, IL: Author.; Lovato, Gradisar, Short, Dohnt, & Micic, 2013 Lovato, N., Gradisar, M., Short, M., Dohnt, H., & Micic, G. (2013). Delayed sleep phase disorder in an Australian school-based sample of adolescents. Journal of Clinical Sleep Medicine, 9, 939–944.; Weitzman et al., 1981 Weitzman, E. D., Czeisler, C. A., Coleman, R. M., Spielman, A. J., Zimmerman, J. C., Dement, W.,… Pollak, C. P. (1981). Delayed sleep phase syndrome. A chronobiological disorder with sleep-onset insomnia. Archives of General Psychiatry, 38, 737–746.). This disorder often includes difficulties initiating sleep, fatigue, daytime sleepiness, concentration difficulties, irritability, depressive symptoms, and anxiety. Social consequences often related to DSPD are truancy, late arrival to school or work, substance abuse, and poor academic performance (Barion & Zee, 2007 Barion, A., & Zee, P. C. (2007). A clinical approach to circadian rhythm sleep disorders. Sleep Medicine, 8, 566–577.; Dagan, Stein, Steinbock, Yovel, & Hallis, 1998 Dagan, Y., Stein, D., Steinbock, M., Yovel, I., & Hallis, D. (1998). Frequency of delayed sleep phase syndrome among hospitalized adolescent psychiatric patients. Journal of Psychosomatic Research, 45, 15–20.; Dewald, Meijer, Oort, Kerkhof, & Bogels, 2010 Dewald, J. F., Meijer, A. M., Oort, F. J., Kerkhof, G. A., & Bogels, S. M. (2010). The influence of sleep quality, sleep duration and sleepiness on school performance in children and adolescents: A meta-analytic review. Sleep Medicine Reviews, 14, 179–189.; Lovato et al., 2013 Lovato, N., Gradisar, M., Short, M., Dohnt, H., & Micic, G. (2013). Delayed sleep phase disorder in an Australian school-based sample of adolescents. Journal of Clinical Sleep Medicine, 9, 939–944.; Ohta, Iwata, Kayukawa, & Okada, 1992 Ohta, T., Iwata, T., Kayukawa, Y., & Okada, T. (1992). Daily activity and persistent sleep-wake schedule disorders. Progress in Neuropsychopharmacology and Biological Psychiatry, 16, 529–537.; Saxvig, Pallesen, Wilhelmsen-Langeland, Molde, & Bjorvatn, 2012 Saxvig, I. W., Pallesen, S., Wilhelmsen-Langeland, A., Molde, H., & Bjorvatn, B. (2012). Prevalence and correlates of delayed sleep phase in high school students. Sleep Med, 13(2), 193–199.; Sivertsen, Harvey, Pallesen, & Hysing, 2015 Sivertsen, B., Harvey, A. G., Pallesen, S., & Hysing, M. (2015). Mental health problems in adolescents with delayed sleep phase: Results from a large population-based study in Norway. Journal of Sleep Research, 24, 11–18.; Sivertsen et al., 2013 Sivertsen, B., Pallesen, S., Stormark, K. M., Boe, T., Lundervold., A. E., & Hysing, M. (2013). Delayed sleep phase syndrome in adolescents: Prevalence and correlates in a large population based study. BMC Public Health, 13, 1663.; Sivertsen, Glozier, Harvey, & Hysing, 2015 Sivertsen, B., Glozier, N., Harvey, A. G., & Hysing, M. (2015). Academic performance in adolescents with delayed sleep phase. Sleep Medicine, 16, 1084–1090.; Thorpy, Korman, Spielman, & Glovinsky, 1988 Thorpy, M. J., Korman, E., Spielman, A. J., & Glovinsky, P. B. (1988). Delayed sleep phase syndrome in adolescents. Journal of Adolescent Health Care, 9, 22–27.).

Despite the distress and dysfunction caused by DSPD, motivation to start treatment and compliance to treatment are often problematic among persons with DSPD (Barion & Zee, 2007Barion, A., & Zee, P. C. (2007). A clinical approach to circadian rhythm sleep disorders. Sleep Medicine, 8, 566–577.). Bright light exposure in the morning is one of the recommended treatments for DSPD (Morgenthaler et al., 2007 Morgenthaler, T. I., Lee-Chiong, T., Alessi, C., Friedman, L., Aurora, R. N., Boehlecke, B.,… Zac, R. (2007). Standards of Practice Committee of the American Academy of Sleep Medicine: Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders [American Academy of Sleep Medicine report]. Sleep, 30, 1445–1459.). To date, there are no evidence-based guidelines for the duration of each LT session, the duration of the total treatment, the intensity of the lamp, or the exact timing in the morning of LT. In clinical practice, LT with bright white light for 30–45 min every morning is often recommended for patients with DSPD (Bjorvatn & Pallesen, 2009 Bjorvatn, B., & Pallesen, S. (2009). A practical approach to circadian rhythm sleep disorders. Sleep Medicine Reviews, 13, 47–60.). For optimal effect, LT in the morning should be combined with dim light in the evening (Hoban & Sulzman, 1985 Hoban, T. M., & Sulzman, F. M. (1985). Light effects on circadian timing system of a diurnal primate, the squirrel monkey. American Journal of Physiology, 249(2), R274–R280.; Rosenthal et al., 1990 Rosenthal, N. E., Joseph-Vanderpool, J. R., Levendosky, A. A., Johnston, S. H., Allen, R., Kelly, K. A.,… Starz, K. E. (1990). Phase-shifting effects of bright morning light as treatment for delayed sleep phase syndrome. Sleep, 13, 354–361.). LT is a safe treatment with only a few side effects that are generally mild and short-lived (Kogan & Guilford, 1998 Kogan, A. O., & Guilford, P. M. (1998). Side effects of short-term 10,000-lux light therapy. American Journal of Psychiatry, 155, 293–294.).

Most studies on the phase-advancing effects of LT on the circadian rhythm have been conducted in healthy subjects under strict laboratory conditions and focused on internal phase markers. These studies demonstrate that the circadian rhythm is affected by light through a phase-response curve. Light before the temperature nadir delays the circadian rhythm, and light after the temperature nadir advances the circadian rhythm (Boivin, Duffy, Kronauer, & Czeisler, 1996Boivin, D. B., Duffy, J. F., Kronauer, R. E., & Czeisler, C. A. (1996). Dose-response relationships for resetting of human circadian clock by light. Nature, 379(6565), 540–542.; Dewan, Benloucif, Reid, Wolfe, & Zee, 2011 Dewan, K., Benloucif, S., Reid, K., Wolfe, L. F., & Zee, P. C. (2011). Light-induced changes of the circadian clock of humans: Increasing duration is more effective than increasing light intensity. Sleep, 34, 593–599.; Khalsa, Jewett, Cajochen, & Czeisler, 2003 Khalsa, S. B., Jewett, M. E., Cajochen, C., & Czeisler, C. A. (2003). A phase response curve to single bright light pulses in human subjects. Journal of Physiology, 549(3), 945–952.; Minors, Waterhouse, & Wirz-Justice, 1991 Minors, D. S., Waterhouse, J. M., & Wirz-Justice, A. (1991). A human phase-response curve to light. Neuroscience Letter, 133, 36–40.; Revell, Molina, & Eastman, 2012 Revell, V. L., Molina, T. A., & Eastman, C. I. (2012). Human phase respose curve to intermittent blue light using a commercially available device. Journal of Physiology, 590(19), 4859–4868.). Bright light (10,000 lux) in a self-administered format has, in a randomized controlled trial, been shown to advance temperature nadir and decreases daytime sleepiness for persons with DSPD (Rosenthal et al., 1990 Rosenthal, N. E., Joseph-Vanderpool, J. R., Levendosky, A. A., Johnston, S. H., Allen, R., Kelly, K. A.,… Starz, K. E. (1990). Phase-shifting effects of bright morning light as treatment for delayed sleep phase syndrome. Sleep, 13, 354–361.). However, a recent study demonstrated that gradually advanced wake-up times combined with bright light (10,000 lux) did not have significantly better effect than gradually advanced wake-up times combined with orange light (400 lux) on sleep diary data and dim light melatonin onset (DLMO) in DSPD (Saxvig et al., 2014 Saxvig, I. W., Wilhelmsen-Langeland, A., Pallesen, S., Vedaa, O., Nordhus, I. H., & Bjorvatn, B. (2014). A randomized controlled trial with bright light and melatonin for delayed sleep phase disorder: Effects on subjective and objective sleep. Chronobiology International, 31, 72–86.).

The aim of the present study was to investigate the effect of self-administered LT with scheduled rise times on the sleep-wake rhythm and daytime functioning. In this study, we also wanted to examine possible predictors of the outcome. To our knowledge, predictors of the effect of scheduled LT in patients with DSPD have so far not been investigated. Daytime sleepiness, anxiety, and depression were investigated as predictors since they are common symptoms in DSPD. Worry and rumination were investigated as possible predictors as they are common clinical features in persons with sleep difficulties (Carney, Harris, Falco, & Edinger, 2013Carney, C. E., Harris, A. L., Falco, A., & Edinger, J. D. (2013). The relation between insomnia symptoms, mood, and rumination about insomnia symptoms. Journal of Clinical Sleep Medicine, 9, 567–575.; Carney, Harris, Moss, & Edinger, 2010 Carney, C. E., Harris, A. L., Moss, T. G., & Edinger, J. D., (2010). Distinguishing rumination from worry in clinical insomnia. Behavioral Research Therapy, 48, 540–546.). Since little is known about how LT should be administered at home, the number of days the LT lamp was used and the daily duration of LT were investigated as possible predictors. Time of DLMO and chronotype preference was investigated as possible predictors since they are measures of the delay in diurnal rhythm. Understanding predicting factors can be important to identify persons with DSPD that might need extra support during LT, and to isolate factors during LT that can improve the treatment response.

Place, publisher, year, edition, pages
Taylor & Francis Group, 2016
National Category
Neurosciences
Identifiers
urn:nbn:se:uu:diva-298760 (URN)10.1080/15402002.2016.1210150 (DOI)
External cooperation:
Available from: 2016-07-07 Created: 2016-07-07 Last updated: 2016-09-02Bibliographically approved

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