Circadian Rhythm Sleep-Wake Disorder

Circadian rhythm sleep-wake disorders related to difficulties in the timing of wakefulness and slumber. These disorders are distinguished by trouble falling asleep, staying asleep, nighttime or early awakenings and low-quality sleep.

The Latin word, circadian, means around the day and refers to an individual’s sleep-wake cycle. People have circadian rhythms, which are 24-hour intervals directing organic processes, such as sleep, wakefulness, hormone secretion, body temperature and digestion. Circadian rhythms impact levels of alertness, as wakefulness waxes and wanes during a 24-hour period. If the body follows its natural cues, circadian rhythm remains balanced, but if the body ignores these cues, circadian rhythm becomes disrupted.

Circadian rhythms are controlled internally by the hypothalamus, but external factors like lightness and darkness may also impact them. People are alert in bright light and drowsy in the dark. In the darkness, the eyes message the hypothalamus and signals drowsiness. The hypothalamus responds by initiating melatonin release in the body, causing fatigue. This process shows how circadian rhythms correspond to daytime and nighttime cycles.

Disturbances in circadian rhythm characterize circadian rhythm sleep-wake disorders. Trouble comes when there is something wrong with a circadian rhythm, or when a discrepancy occurs between circadian rhythm and the outside environment. This disruption can impact the timing and length of sleep and may cause insomnia or significant fatigue.   

What is Circadian Rhythm Sleep-Wake Disorder?

Circadian rhythm sleep-wake disorders are irregularities in the timing, duration and stringency of the sleep-wake cycle as it relates to day and night cycles. Circadian rhythm sleep-wake disorders are inherently related to difficulties in the timing of wakefulness and slumber. These disorders are distinguished by trouble falling asleep, staying asleep, nighttime or early awakenings and low-quality sleep.

There are five types of circadian rhythm sleep-wake disorders characterized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). If a person’s circadian rhythm sleep-wake disorder is causing significant impairment and negatively impacting an individual’s daily functioning at home, school or work, then a clinician may make a diagnosis. The five types of circadian rhythm sleep-wake disorders are as follows:

• Delayed sleep phase type occurs when it takes an individual more than two hours to fall asleep from the time that they go to bed. Individuals with this type of disorder have trouble waking up in the morning and are excessively drowsy and sluggish in the morning.
• Advanced sleep phase type happens when sleep and wake times are hours in advance of desired times. People with this type of disorder fall asleep at least two hours earlier than intended and wake too early in the morning and remain tired throughout the day.
• Irregular sleep-wake type is a state where individuals have no clear circadian rhythm and, thus, sleep is disjointed into at least three stages during a twenty-four-hour period. Individuals experience insomnia at night and are sleepy and napping during the day with no solid period of sleep.
• Non-twenty-four-hour sleep-wake type occurs when an individual’s circadian rhythm does not coincide with a twenty-four-hour cycle, causing insomnia and excessive fatigue. A person’s natural sleep period will become later and later, causing their sleep time to coincide with daytime.   
• Shift-work type occurs when an individual’s work schedule does not align with a typical daytime work schedule, resulting in excessive fatigue at work and inability to sleep during the day.

Symptoms of Circadian Rhythm Sleep-Wake Disorder

Regardless of type, circadian rhythm sleep-wake disorders share several similar symptoms. People with these disorders may struggle to fall asleep, to stay asleep and to obtain restorative sleep. Poor quality sleep may result in:

• Excessive drowsiness
• Decreased cognition
• Impaired academic or occupational functioning
• Difficulty concentrating
• Deficient coordination
• Headaches
• Gastrointestinal issues
• Depression

Causes of Circadian Rhythm Sleep-Wake Disorder

Genetic or hereditary factors may not play a role in an individual’s circadian rhythm. However, some types begin early in life and link with a family history. Several circumstances can prompt a circadian rhythm sleep-wake disorder, including:

• Light exposure and hypersensitivity to environment
• Environmental factors, such as noise levels, raised temperatures and excessive light
• Jet lag, especially related to the course of travel and amount of time zones traversed
• Neurodegenerative diseases, such as Alzheimer disease or dementia
• Shift work that alters quickly
• Lifestyle of staying up late   

Diagnosing Circadian Rhythm Sleep-Wake Disorder

Some diagnostic tools that may be able to diagnose circadian rhythm sleep-wake disorders can include:

• Sleep Log encompassing a two-week period.
• Sleep Diary to assess and describe the quality of sleep.
• Imaging Studies like a CT scan and MRI, to evaluate for neurodegenerative disease.
• Multiple sleep latency tests to measure levels of lethargy and tiredness.
• Epworth Sleepiness Scale, which evaluates individual responses to situations related to tiredness.
• Actigraphy, which calculates wrist motion to assess sleep-wake cycle.

Who is at Risk for Circadian Rhythm Sleep-Wake Disorder?

Certain risk factors make individuals susceptible to a circadian rhythm sleep-wake disorder. Disturbances stemming from childhood can arise from faulty conditioning, like never learning how to fall or stay asleep. An absence of predictable nighttime routines or reliable sleep schedules can increase the risk for development of a sleeping disorder. Mental, emotional or environmental factors, like stress or trauma, can develop a disorder. A troublesome event, like a loss, medical crisis or abuse may cause sleep-wake disorders.  

Circadian Rhythm Sleep-Wake Disorder Statistics

In an effort to discover effective treatments for Circadian Rhythm Sleep-Wake disorders, studies have been conducted and some of the statistics found in research include:

• Advanced sleep-wake phase is rare and estimated to arise in only one percent of middle-aged adults.
• Advanced sleep-wake phase is more common in older adults and the geriatric population.
• Non-twenty-four-hour sleep-wake type is most prevalent in the blind population, with fifty to seventy-five percent of blind patients having the disorder.  
• Delayed sleep phase type is present in seven to sixteen percent of teens and young adults.  
• Irregular sleep-wake rhythm disorder is rare, and incidence is wholly unknown.  Despite this fact, this disorder most often impacts older adults, especially those with neurodegenerative disorders like Alzheimer’s disease and dementia.

Circadian Rhythm Sleep-Wake Disorder Treatment

Treatment for circadian rhythm disorders depends on the type, magnitude and level of impairment that a sleeping disorder has on day to day functioning. It is critical to individualize treatment because sleep disorders vary among individuals. Treatment options can include behavioral therapy, medication and psychotherapy.  

Treatment should be geared primarily to address the specific subtype of a person’s sleep-wake disorder, for example:

• Delayed sleep phase syndrome treatment includes promoting healthy sleep schedules, positive sleep hygiene, advancing or hindering internal clock and sleep-inducing drugs.
• Treatment for advanced sleep-wake phase disorder uses light therapy and behavioral change to maintain bedtime and nighttime alertness to increase the chances of awakening later in the morning.
• Irregular sleep-wake type treatment involves enhanced situations to reset the internal clock.
• Treatment for non-twenty-four-hour sleep-wake disorder aims to reset the internal clock to match the twenty-four-hour day and night cycle.  
• Shift-work type treatment assists individuals stay alert during work and stay asleep during downtime.

Medications for Treating Circadian Rhythm Sleep-Wake Disorder

Several medications can treat circadian rhythm sleep-wake disorder. Melatonin is a hormone produced by the pineal gland that assists the body in understanding when it is time to sleep and awaken. The body should produce more melatonin at night once the sun goes down and less in the morning when the sun rises. An individual’s internal clock and exposure to light dictate how much melatonin the body produces. Melatonin is available in over the counter pill, liquid or chewable supplements.  

Rozerem, a melatonin receptor stimulant can promote sleep onset and help stabilize circadian rhythm disorders. Rozerem requires a prescription from a physician and works differently from melatonin, because this medication stimulates melatonin brain receptors.

Short-term sleep aids, like benzodiazepines, encourage sleep. People use benzodiazepines, like Xanax, in conjunction with behavioral therapy techniques, and physicians may prescribe them during the initial phases of a circadian rhythm disorder. Long-term use of these medications is not suggested, due to potential side effects and the risk of dependency.  

Eugeroics, or wakefulness promoting agents, promote awareness and attentiveness, and people may use them to regulate and uphold optimal sleeping schedules. Additionally, this class of drug has a low possibility of dependency.

Therapy for Treating Circadian Rhythm Sleep-Wake Disorder

Behavior treatments include:

• Chronotherapy is a behavioral intervention where patients change their sleep times until a patient reaches his or her desired bedtime. Individuals can either delay or advance scheduled bedtimes until they reach an ideal time. There must be a firm investment in this process because it will take several weeks to adjust the sleep-wake cycle successfully. Once a patient reaches a good time, they must be consistent to maintain it.
• Bright Light Therapy resets an individual’s inner clock and people may use it to begin or delay sleep. The timing of this therapeutic intervention is important and requires oversight from a sleep specialist. A high-intensity light is essential, and the length of therapy fluctuates from one to two hours, depending on specific individual needs.
• Environmental Cue Enhancement involves making changes to an individual’s sleep environment. People need to maintain consistency with eating schedules and to avoid light stimulation shortly before bedtime. Additionally, individuals are encouraged to keep a dark, silent room during sleep and a brightly lit room upon awakening.  
• Sleep Hygiene Maintenance promotes behaviors to assist quality sleep patterns. Proper sleep hygiene stresses consistency with bedtime and awakening routines, the termination of napping behaviors during the daytime and avoiding heavy meals and fluid intake before bedtime. Other positive sleep hygiene techniques include avoiding caffeine, cigarettes, alcohol and stress before bedtime.
• Exercise promotes high-quality sleep and increases energy during waking hours. Exercise should always be done in the morning or afternoon and not near bedtime.  
• Mind/Body Interventions include meditation, yoga and biofeedback to assist with relaxation and tension reduction. Guided imagery and visualization exercises before bed can also prompt relaxation.
• Individual Psychotherapy will target areas of a person’s life that increase and perpetuate anxiety, which then serves to disrupt healthy sleeping patterns.

Circadian Rhythm Sleep-Wake Disorder and Substance Abuse

Substance abuse associates with various psychological and physical health difficulties, including unstable sleep patterns. The relationship between substance use and sleep appear to be bi-directional, meaning that substance misuse may precipitate sleep disturbance and sleep disturbance may pose an elevated risk for substance misuse.

The effects of substance use worsen symptoms of circadian rhythm sleep-wake disorder. Symptoms already present as part of the sleep disorder can unite with symptoms developing from the substance use, magnifying them and making them more problematic.   

Research has found that there is a link between circadian rhythm and addiction because people with addictions are more likely to have sleep disorders. Circadian rhythms can also be the reason why individuals portray twenty-four-hour patterns of drug use.   

Circadian Rhythm Sleep-Wake Disorder and Alcohol

Individuals may use alcohol to fall asleep, but research has found that it can have the opposite effect in disrupting sleep and interfering with the body’s internal clock. The internal clock coordinates physiological functions in the body so that they occur at appropriate times and match with daylight. Chronic alcohol misuse diminishes the internal clock’s ability to coordinate daily activities, disturbs activity patterns and continues to have a significant impact on the internal clock even after drinking concludes.

Circadian Sleep-Wake Disorder and Marijuana

Individuals that use marijuana believe that cannabis helps them sleep, but marijuana use may disrupt circadian rhythm. Marijuana use can also cause an individual to have a distorted perception of time. Additionally, research has found that nerve cells in the brain directly impact circadian rhythm.   

Circadian Rhythm Sleep-Wake Disorder and Stimulants

Stimulants heighten brain activity, which may make it difficult for individuals to slow down and relax. Stimulants may make individuals more alert and less sleepy, and if taken in excess, they can greatly prolong sleep onset. Research has found that cocaine, an addictive stimulant, can impact the genes affiliated with circadian rhythm. These same genes have also been shown to regulate dopamine, which is involved with reward pathways of cocaine.

Treatment for Circadian Rhythm Sleep-Wake Disorder with Co-Occurring Substance Abuse

Therapists may treat sleep-wake disorders compounded with co-occurring substance misuse issues with behavior therapy and psychotropic medication. Over the counter medications, such as melatonin, should not be taken without the knowledge of a physician if substance misuse issues are present.  

Benzodiazepines are short-acting sleep aides and work well to fall asleep. However, there is some debate as to the safety of using this class of drugs on individuals with substance use disorders, especially those struggling with alcoholism. Benzodiazepines have the potential to be misused if not taken as prescribed, thus leaving the possibility for dependence, especially amongst alcoholics.  

If you are experiencing symptoms of circadian rhythm sleep-wake disorder, there are various methods to diagnose and treat the disorder, including behavior therapy and psychotropic intervention. If your sleep-wake disorder is co-occurring with a substance use disorder, help is available. At The Recovery Village, a team of professionals offers a number of treatment programs for substance use and co-occurring disorders like sleep-wake disorders. Call and speak with a representative to learn more about which program could work for you.

Editor – Jennifer Kopf

Jennifer Kopf is a Florida-based writer who likes to balance creative writing with helpful and informative pieces. Her passion for helping people has translated into writing about the importance of treatment for substance use and mental health disorders. Read more

Medically Reviewed By – Tracy Smith, LPC, NCC, ACS

Tracy Smith is a Licensed Professional Counselor, a Nationally Certified Counselor, an Approved Clinical Supervisor, and a mental health freelance and ghostwriter. Read more