An advanced circadian phase leads to sleepiness and the ability to fall asleep early in the evening, followed by a tendency to awaken spontaneously relatively early in the morning. In extreme cases, patients with these “lark” tendencies may be diagnosed with advanced sleep phase disorder. Persistent early morning awakening insomnia and sleep maintenance complaints are common.
A delayed circadian phase is associated with inability to fall asleep at a typical late evening bedtime and difficulty awakening at a desired time the following morning. In extreme cases, individuals may sleep from very late at night until the following afternoon. These markedly delayed schedules may be obvious, but the circadian contribution may not be recognized in less severe cases.
People with this predisposition may achieve optimum sleep by following their delayed circadian tendency, but school and work demands often conflict with this approach. They may develop chronic sleep deprivation from late sleep onset coupled with forced morning awakenings. Complaints of chronic difficulty with sleep onset are common.
Recommendation. Have the patient keep a sleep log to demonstrate advanced or delayed circadian phase tendencies. Determine if the patient is a shift worker who is attempting to sleep in the daytime. Consider prescribing ramelteon—a melatonin agonist—and providing strategic bright light exposure:
- in the evening for advanced circadian phase patients
- in the morning for delayed circadian phase patients.8
6 Is the patient following appropriate sleep hygiene?
Sleep hygiene will not necessarily cure chronic insomnia, but inattention to basic guidelines (Table 2) can undermine other treatments. When re-evaluating patients with chronic insomnia, give special attention to their alcohol and caffeine intake, regularity of bedtime and wake-up times, meal times, and the bedroom environment. Advise patients to remove televisions from the bedroom, for example.
CBT that is effective for chronic insomnia typically blends sleep hygiene with education, cognitive psychotherapy, and specific instructions regarding bedtime schedules.9,10 Relaxation techniques also may be beneficial.
Consider consulting with a sleep specialist if the patient has not been evaluated at a sleep center. Some sleep centers offer CBT.
Table 2
Patient education: Sleep hygiene guidelines
| Try to maintain a regular sleep–wake schedule |
| Avoid afternoon or evening napping |
| Allow yourself enough time in bed for adequate sleep duration (such as 11 PM to 7 AM) |
| Develop a relaxing evening routine for the hours before bedtime |
| Spend some idle time reflecting on the day’s events before going to bed; make a list of concerns and how some might be resolved |
| Reserve the bed for sleep and sex; do not do homework, pay bills, watch TV, or engage in serious domestic discussions in bed |
| Avoid alcohol in the evening |
| Avoid caffeine in the afternoon and evening |
| Minimize annoying noise, light, or temperature extremes |
| Consider a light snack before bedtime |
| Exercise regularly, but not late in the evening |
| Do not try harder and harder to fall asleep; if you can’t sleep, get out of bed and do something else, in another room if possible |
| Avoid smoking |
7 Does the patient regularly experience anxiety and tension as bedtime approaches or spend excessive wakeful time in bed?
Patients who tend to be anxious, depressive, or emotionally reactive are at increased risk for developing an insomnia episode. They then may develop conditioned hyperarousal associated with preparing for and getting into bed, which perpetuates insomnia.
Some patients spend long periods in bed, hoping to achieve any possible sleep that night. Extended time in bed can perpetuate insomnia by increasing frustrating time awake, thereby reinforcing the association between the bed and wakefulness.
Recommendation. CBT often helps ease these conditioned responses.
Stimulus control can help anxious individuals reassociate the bed, bedroom, and bedtime routines with sleep onset, rather than sleep-destructive tension. Advise patients to go to bed in the evening when they feel they can fall asleep. If they do not fall asleep within 10 to 15 minutes or experience their usual worry and frustration about not sleeping, instruct them to leave the bed and try again later. Also tell them to avoid daytime napping.
Sleep restriction therapy may help patients with excessive wakefulness in bed by limiting sleep opportunity to defined hours of the night. For example, a patient who reports getting 5 hours of sleep would be scheduled for 5 hours in bed. If his typical arising time is 7 am, he would not go to bed until 2 am. When his sleep log shows he has slept 90% of the time in bed for 5 consecutive nights, he can go to bed 15 to 30 minutes earlier. Over time, as this process is repeated, patients spend greater amounts of time sleeping while in bed.