Circadian Rhythm Sleep Disorders (CRSD) in Psychiatry-A Review

By Dagan, Yaron | The Israel Journal of Psychiatry and Related Sciences, January 1, 2002 | Go to article overview

Circadian Rhythm Sleep Disorders (CRSD) in Psychiatry-A Review


Dagan, Yaron, The Israel Journal of Psychiatry and Related Sciences


Abstract: Circadian Rhythm Sleep Disorders (CRSD) are a group of sleep disorders characterized by a de-synchronization between a person's biological clock and the environmental 24-hour schedule. There are four main types of CRSD, namely, Delayed Sleep Phase Syndrome (DSPS) (the most common), Advanced Sleep Phase Syndrome (ASWD), Non-24-hour Sleep-Wake Syndrome (Free-Running Pattern) and Irregular (or Disorganized) Sleep Wake Pattern. These disorders lead to harmful psychological and functional difficulties and certain personality disorders may also be related to them. It has been found that psychotropic drugs, SSRI and haloperidol can cause CRSD, and this is also true for some cases of minor head trauma. They are often misdiagnosed and incorrectly treated due to the fact that many doctors are unfamiliar with them. This review describes the disorders, their consequences and available treatment.

Human beings sleep at night and are awake during the day. This essential phenomenon so taken for granted can become chronically impaired in some people, leading to a group of disorders called: Circadian Rhythm Sleep Disorders (CRSD). These disorders have an extremely important relevance to psychiatry, but psychiatrists are often unfamiliar with them. The aim of this article is to shed some light on these disorders and emphasize their importance in psychiatry. Most of the data is based on our clinical experience with CRSD and from research work carried out in this field.

Characteristics of CRSD

The sleep-wake schedule is controlled by two basic mechanisms: one is an inborn pacemaker that regulates the sleep-wake cycle, which has an endogenous schedule longer than 24 hours. The second mechanism is responsible for the synchronization of this internal clock to the external 24-hour day, and reacts to behavioral environmental time signals - zeitgebers. The biological zeitgeber - bright light - seems to play the crucial role in this process (1, 2).

Twenty years ago Weitzman et al. (3) first described 30 of their insomnia patients (7%) as suffering from Delayed Sleep Phase Syndrome (DSPS). These patients had a tendency to fall asleep very late at night and to experience difficulty rising at a desired time in the morning. Weitzman et al. also found that when these patients were allowed to sleep without external restrictions, they slept for a normal length of time and exhibited no pathology in their sleep architecture. These patients were younger than other types of insomniacs, with no difference of sex prevalence, displaying no specific psychiatric disorders, and of various ages of onset. This discovery led to the recognition and identification of Circadian Rhythm Sleep Disorders (CRSD) other than DSPS. Today, the criteria for the definition and diagnosis of CRSD are described by the International Classification of Sleep Disorders (ICSD) (4) and are also documented in American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSMIV) (5).

Circadian Rhythm Sleep Disorders manifest themselves as a misalignment between the patient's sleep pattern and that which is desired or regarded as the societal norm. Sleep episodes occur at inappropriate times, often causing wake periods to occur at undesired times. Therefore, the patient complains of insomnia or excessive daytime sleepiness. For most of the CRSD patients, the major sleep episode is of normal duration with normal REM/NREM cycling, although intermittent sleep episodes may occur in some disorders

CRSD are divided into four major subgroups (4):

1)Delayed Sleep Phase Syndrome (DSPS): in this disorder the major sleep episode is delayed in relation to the desired clock time resulting in symptoms of sleep-onset insomnia and difficulty in awakening at the desired time.

2) Advanced Sleep Phase Syndrome (ASPS): the major sleep episode is advanced in relation to the desired clock time, resulting in symptoms of compelling evening sleepiness, early sleep onset, and an awakening that is earlier than desired. …

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