Circadian Rhythm Sleep Disorder: Health Risks and Treatment
The 2nd edition of the ESRS Sleep Medicine Textbook is an invaluable resource for the latest information on circadian rhythm sleep disorders. The summaries that follow offer insights into the Sleep Medicine Textbook chapters on Health Risks and Treatment.
Health Risks
Delayed sleep-wake phase disorder is associated with chronic sleep loss, absenteeism, impaired school, work, and subjective cognitive performance. The disorder shows comorbidity with mental disorders such as depression, attention-deficit hyperactivity disorder, obsessive-compulsive disorder, bipolar disorder, and autism. Patients with advanced sleep-wake phase disorder (ASWPD) normally experience sleep loss if not adhering to an early bedtime. ASWPD often impairs social activities and has been associated with depression as well as autism. Irregular sleep-wake rhythm disorder is associated with impaired daytime functioning and has been linked especially to dementia, but also to schizophrenia, rare developmental syndromes, and brain injuries. Non-24-hr sleep-wake rhythm disorder (N24SWRD) is relatively often found in blind people and causes significant impairment in daytime functioning. Depression seems to be a potent consequence of N24SWRD. Jet lag disorder (JLD) impairs athletic and cognitive performance. It also impairs the ability to eat, sleep, and exercise efficiently. JLD can worsen psychotic symptoms. Recurrent JLD may disturb reproductive health and may be carcinogenic. Shift and night work are associated with impaired sleep and increased sleepiness, accidents, gastrointestinal dysfunction, metabolic disturbances, certain cancers, impaired reproductive and mental health, as well as increased mortality. Short rest between consecutive shifts is associated with several negative outcomes. Shift workers with shift work disorder (SWD) typically report poorer health and function on most parameters than shift workers without SWD. Common denominators across circadian rhythm sleep-wake disorders in regards of symptoms are inability to sleep adequately at night, daytime sleepiness/ impairment, and various symptoms of decreased mental health, of which depressive symptoms seem to occur most frequently.
Keywords:
behavioural therapy, bright light therapy, chronotherapy, circadian rhythms, dark therapy, light exposure, melatonin, resynchronization, Zeitgebers
Summary by:
Stale Pallesen and Bjørn Bjorvatn (2021). F. Circadian Rhythm Sleep Disorders 5. Health Risks. In Bassetti, C., McNicholas, W., Paunio, T., & Peigneux, P. (Eds.). Sleep Medicine Textbook (2nd ed., pp. 483-492). Regensburg: European Sleep Research Society.
Treatment
Effective management of circadian rhythm sleep-wake disorders (CRSWD) requires initially an assessment of the patient’s sleep-wake schedules, with an accurate estimation of circadian phase, and secondly close therapeutic follow-up. The main tools at the disposal of the clinician are, with large-scale accessibility, sleep logs and questionnaires and to a lesser extent actigraphy due to its cost. These tools are essential and can be sufficient for the diagnosis and therapeutic follow-up. The assessment of reliable markers of circadian phase with the measure of dim light melatonin onset and core body temperature nadir (CBTmin) are less used because of their cost and the expertise they require. They are therefore reserved for complex cases or when previous therapeutics were unsuccessful. Behavioural interventions are the bedrock of CRSWD therapeutics. They aim to raise awareness and educate the patient on accurate exposure to time cues through an understanding of their impact on the internal circadian clock. Bright light therapy and exogenous melatonin are considered as the treatments of choice, but their application at inappropriate times can worsen the patient’s condition. This is explained by a phase-dependent effect of light and melatonin. Exposure to bright light before the CBTmin phase delays the circadian rhythm, whereas light administered after the CBTmin phase advances it. Exogenous melatonin induces a phase advance when administered in the evening before endogenous melatonin onset, whereas it can induce a phase delay when administered during the second half of the night (several hours after dim light melatonin onset). Chronotherapy may be used when a phase shift of several hours is required, as in the case of an inversion of the circadian rhythm. Sleep and wake times will be delayed every day until the desired sleep and wake times are achieved. However, its efficiency is less well documented and, if not well monitored, it can lead to a free run. Therefore, its use should be limited for use by experienced physicians and under close clinical follow-up. Pharmacological stimulants or hypnotics have been proposed to counteract respectively CRSWD-i nduced daytime somnolence or insomnia, although their regular use is not recommended. A combination of behavioural, photic, and pharmacological strategies can be more efficient than each treatment in isolation. The success rate will depend on the type of CRSWD, its severity, the accuracy of the estimation of the circadian phase, the associated comorbidities, and the patient’s commitment to treatment. Given the burden and cost of CRSWD to society, further development of efficient diagnostic and follow-up tools and personalized therapeutics are required.
Keywords:
behavioural therapy, bright light therapy, chronotherapy, circadian rhythms, dark therapy, light exposure, melatonin, resynchronization, Zeitgebers
Summary by:
Ülker Kilic Huck, Carmen Schroder and Patrice Bou rgin (2021). F. Circadian Rhythm Sleep Disorders 6. Treatment. In Bassetti, C., McNicholas, W., Paunio, T., & Peigneux, P. (Eds.). Sleep Medicine Textbook (2nd ed., pp. 493-505). Regensburg: European Sleep Research Society.
Previous related chapters on circadian rhythm sleep disorders include: Nosological classification, definitions, and epidemiology, Shift work, Delayed sleep-wake phase disorder and Non-24-hour sleep-wake disorder and Clinical picture, diagnosis and Comorbidities.
Recent publications from ESRS members
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- Morais et al. (2023). Protein tyrosine phosphatase receptor type delta (PTPRD) gene in an animal model of restless legs syndrome. J Sleep Res.
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- Tellenbach et al. (2023). REM sleep and muscle atonia in brainstem stroke: A quantitative polysomnographic and lesion analysis study. J Sleep Res.
- Mead, Reid and Knutson (2023). Night-to-night associations between light exposure and sleep health. J Sleep Res.
- Meule, Riemann and Voderholzer (2023). Sleep quality in persons with mental disorders: Changes during inpatient treatment across 10 diagnostic groups. J Sleep Res.
- Gustin et al. (2023). French Sleepiness Scale for Adolescents-8 items: A discriminant and diagnostic validation. Encephale.
- Rault et al. (2023). A real-time automated sleep scoring algorithm to detect refreshing sleep in conscious ventilated critically ill patients. Neurophysiologie Clinique.
- Hrozanova et al. (2023). Group-delivered cognitive behavioural therapy versus waiting list in the treatment of insomnia in primary care: study protocol for a pragmatic, multicentre randomized controlled trial. BMC Prim. Care.
- Bilterys et al. (2023). Relationship, differences, and agreement between objective and subjective sleep measures in chronic spinal pain patients with comorbid insomnia: a cross-sectional study. Pain.