Circadian rhythm sleep disorders occur when people’s internal sleep-wake schedule (clock) does not align with the earth’s cycle of darkness (night) and light (day).
Jet lag and shift work commonly disturb the usual rhythms of sleep and waking.
People who have a circadian rhythm sleep disorder cannot awaken or go to sleep at normal hours.
Doctors base the diagnosis on symptoms, sometimes using information from a sleep log and sleep laboratory testing.
Good sleep habits and exposure to bright light initially after waking can help people readjust their sleep-wake cycle.
(See also Overview of Sleep.)
Circadian rhythms are the regular changes in mental and physical states that occur in about a 24-hour period—a person’s internal clock. These rhythms are controlled by an area of the brain that is influenced by light (called the circadian pacemaker). After entering the eye, light stimulates cells in the back of the eye (retina) to send nerve impulses to this area. These impulses signal the brain to stop producing melatonin, a hormone that promotes sleep.
Normally, people vary in their sleep and wake times. Some people (morning people or larks) prefer to go to sleep and wake early. Others (night people or owls) prefer to go to sleep and wake late. Such variations are not considered a disorder as long as people can do the following:
Wake up when they need to do something in the morning and fall asleep the night before in time to get enough sleep before having to get up
Sleep and wake up at the same time every day, if they want to
Adjust to new sleep and wake times within a few days after they start a new routine
People with a circadian rhythm sleep disorder fall asleep at inappropriate times and then cannot go to sleep or wake up when they need or want to. Their sleep-wake cycle is disrupted.
Causes of Circadian Rhythm Sleep Disorders
Causes of circadian rhythm sleep disorders may be internal or external.
Internal causes include the following:
Damage to the brain—for example, due to a brain infection (encephalitis), stroke, head injury, or Alzheimer disease
Insensitivity to the cycle of night and day
External causes include the following:
Jet lag (especially when traveling from west to east)
Working irregular shifts on a regular basis
Frequently going to bed and getting up at different times
Being confined to bed for a long time
Blindness or not being exposed to sunlight for long periods of time
Taking certain medications (or illicit drugs)
Sleep-wake reversals are common among people who are hospitalized because they are often awakened during the night and because their eyes are not exposed to sunlight long enough during the day.
There are several types of circadian rhythm disorders.
Jet lag disorder is caused by rapid travel across more than 2 time zones.
Shift work disorder varies in severity depending on
How often shifts change
How much they change
Whether they make sleep and wake times earlier or later
How many consecutive nights are worked
How long the shift lasts
Always working night or evening shifts and keeping the same bed times on days off is preferable. However, even then, daytime noise and light may interfere with sleep. Also, workers often shorten their sleep time and sleep at different times on days off to participate in social or family events.
Delayed sleep phase disorder occurs when people consistently go to sleep and awaken late (for example, go to sleep at 3 AM and wake up at 10 AM or as late as 1 PM). This syndrome is more common among adolescents and young adults than in adults. People with delayed sleep phase disorder cannot fall asleep earlier even if they try.
Advanced sleep phase disorder occurs when people consistently fall asleep and awaken early and cannot change this pattern. It is more common among older adults. People with advanced sleep phase disorder cannot stay awake until later times even if they try.
Non–24-hour sleep-wake syndrome occurs when the sleep-wake cycle changes every day. The length of the sleep-wake cycle remains the same, but it is more than 24 hours. Thus, sleep and wake times are delayed by 1 to 2 hours each day. This syndrome is much less common and tends to occur in blind people.
Symptoms of Circadian Rhythm Sleep Disorders
Because people cannot sleep when they need to, they may be sleepy during the day and have difficulty concentrating, thinking clearly, and doing their usual activities. They may misuse alcohol, sleep aids, and stimulants in an effort to sleep or stay awake.
Symptoms of circadian rhythm sleep disorders may be worse when people change their sleep schedule frequently, as when they frequently travel across several time zones or change their shift at work. Symptoms are also worse if the change makes wake and sleep times earlier (advances the sleep cycle) because delaying sleep is easier than going to sleep earlier. The sleep cycle is advanced when people fly east.
If the cause is external, the timing of other circadian body rhythms, including temperature and hormone secretion, is affected. Thus, people may feel generally unwell, irritable, nauseated, and depressed, as well as sleepy. The risk of heart and metabolic disorders may also be increased.
If the cause of the disruption can be corrected, symptoms resolve over several days as rhythms readjust. In older adults, resolution may take a few weeks or months.
Diagnosis of Circadian Rhythm Sleep Disorders
A doctor's evaluation
Doctors suspect the diagnosis based on symptoms. People are usually asked to keep a sleep log and to record their sleep and wake times for several weeks. Testing in a sleep laboratory is rarely needed.
Treatment of Circadian Rhythm Sleep Disorders
Changes in behavior
Sleep aids and, when awake, occasionally drugs to stimulate the brain
Developing good sleep habits can help.
Changes in Behavior to Improve Sleep
What to Do | How to Do It |
|---|---|
Follow a regular sleep-wake schedule | People should go to bed at the same time each night and, more importantly, get up at the same time each morning, even on weekends and vacations. People should not spend too much time in bed. |
Follow a regular routine before bedtime | A regular pattern of activities—such as listening to soft music, brushing the teeth, washing the face, and setting the alarm clock—can set the mood for sleep. This routine should be followed every night, at home or away. As part of this routine, people should avoid bright lights before bedtime. Limiting use of a cell phone, computer, and television a few hours before bedtime can also help. |
Make the environment conducive to sleep | The bedroom should be kept dark, quiet, and not too warm or too cold. Loud noises can disturb sleep even when people are not awakened by them. Wearing ear plugs, using a white-noise machine or a fan, or installing heavy curtains in the bedroom (to block out outside noises and light) can help. Wearing a mask over the eyes can help people who must sleep during daylight in a room that cannot be completely darkened. If people wake up during the night, they should avoid bright lights. |
Use pillows | Pillows between the knees or under the waist can make some people more comfortable. For people with back problems, lying on the side with a large pillow between the knees or lying on the back with a large pillow under the knees may help. |
Use the bed primarily for sleeping | The bed should be used for sleep and sex. It should not be used for eating, reading, watching television, paying bills, texting or emailing on a phone or laptop, or other activities associated with being awake. |
Get up | When people are unable to fall asleep within 20 minutes, getting up and doing something else in another room and coming back to bed when sleepy may be more effective than lying in bed and trying harder and harder to fall asleep. |
Exercise regularly | Exercise can help people fall asleep naturally. However, exercise within 5 hours of bedtime can stimulate the heart and brain and keep people awake. |
Relax | Stress and worry interfere with sleep. People who are not sleepy at bedtime can relax by reading or taking a warm bath. Relaxation techniques, such as visual imagery, progressive muscle relaxation, and breathing exercises, can be used. People can aim to leave their problems at the bedroom door. Scheduling a worry time during the day to think about concerns can diminish the need to worry at bedtime. |
Avoid stimulating activity before bedtime | Watching exciting television shows or sports events, playing thrilling computer games, or dealing with complicated work-related matters during the hour or so before bedtime can make sleeping difficult. |
Avoid substances that interfere with sleep | Food and beverages that contain alcohol or caffeine |
Eat a light snack | Hunger can interfere with going to sleep. Occasionally, eating a light snack, especially if warm, can help, unless a person has gastroesophageal reflux. However, people should aim to stop eating at least a few hours before bedtime and not eat any meals, especially heavy meals, near bedtime. Heavy meals may cause heartburn, which can interfere with sleep. |
Eliminate behaviors that provoke anxiety | People can turn the clock away so that time is not a focus. They should not watch the clock while they are in bed. |
Spend time in bright light during the day | Exposure to light during the day can help people readjust their sleep-wake schedule to be in sync with the earth’s cycle of light and dark. |
Avoid daytime naps, except for shift workers and people with narcolepsy | Daytime naps may interfere with sleeping at night in people with insomnia. However, naps reduce the need for medications in people with narcolepsy and improve performance in shift workers. If needed, naps should be taken at the same time each day and limited to 30 minutes. |
Exposure of the eyes to bright light at appropriate times may be the most helpful strategy. Such exposure helps reset the internal clock. For example, to minimize jet lag, travelers should spend time in sunlight, particularly in the morning, after they reach their destination. Shift workers should spend time in bright light (sunlight or artificial light) at times when they should be awake. Wearing sunglasses on the way home from work reduces exposure to bright light before bedtime and may help shift workers fall asleep more easily after arriving home, but wearing them should be avoided if doing so causes drowsiness while driving. While shift workers are asleep, they should make the bedroom as dark and quiet as possible. Sleep masks and white-noise devices can be used. Exposure to bright light in the morning may help people with delayed sleep disorder. Bright light in the evening may help people with advanced sleep disorder.
Another strategy is to gradually shift the sleep-wake schedule to the one that is desired. Travelers may benefit from gradually shifting their schedule to approximate that of their destination, beginning well ahead of travel time.
