Psych · Specialty psychiatry — sleep medicine interface
Circadian rhythm sleep-wake disorders
Also known as CRSWD · Delayed sleep-wake phase disorder · DSWPD · DSPD · Advanced sleep-wake phase disorder · Non-24-hour sleep-wake disorder · Free-running disorder · Shift work sleep disorder · Jet lag disorder · Irregular sleep-wake rhythm · Chronotherapy · Melatonin phase shift
Exam-exhaustive fellowship atlas on circadian rhythm sleep-wake disorders — DSM-5-TR/ICSD-3 nosology (DSWPD, ASWPD, non-24, ISWRD, shift work, jet lag), SCN/two-process physiology and PRCs, DLMO/actigraphy assessment, timed light and melatonin, tasimelteon for blind non-24, shift-work countermeasures including modafinil evidence, ADHD/bipolar/adolescence interfaces, and BAP/AASM guideline framing. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Reduced need for sleep with elevated/irritable mood and increased energy — mania/hypomania pathway, not DSWPD
- Night-shift near-miss driving or machinery incident — remove from safety-critical duty and treat shift-work sleepiness as occupational emergency
- Progressive free-running schedule with functional collapse or severe depression — risk assess suicide and refer specialty sleep/chronobiology
- New multiphasic fragmented sleep in older adult with cognitive decline — consider ISWRD and neurodegeneration work-up, not only 'insomnia'
- Forced extreme chronotherapy without bipolar safety planning — can destabilise mood
- Blind patient with cyclic night insomnia and daytime sleepiness — consider non-24, not primary insomnia alone
Meet the patient
A 17-year-old cannot get to sleep before 3 am and cannot wake for school. On holidays he sleeps 3 am to 11 am and feels entirely well. His parents call it laziness; his teachers call it truancy. He is failing, miserable, and has been started on a nightly Z-drug that does nothing.[3][11]
The whole topic is in that holiday sentence. The exam question he answers: "Is this primary insomnia, and what is the one test that sorts it?" — let him sleep on his preferred late schedule and watch him sleep perfectly. That is delayed sleep-wake phase disorder, and the answer is timed light and melatonin, not a sedative.[3][5]
References13ShowHide
- [1]Auger RR, Burgess HJ, Emens JS, et al. Clinical Practice Guideline for the Treatment of Intrinsic Circadian Rhythm Sleep-Wake Disorders: Advanced Sleep-Wake Phase Disorder (ASWPD), Delayed Sleep-Wake Phase Disorder (DSWPD), Non-24-Hour Sleep-Wake Rhythm Disorder (N24SWD), and Irregular Sleep-Wake Rhythm Disorder (ISWRD). An Update for 2015: An American Academy of Sleep Medicine Clinical Practice Guideline J Clin Sleep Med, 2015.PMID 26414986
- [2]Sack RL, Auckley D, Auger RR, et al. Circadian rhythm sleep disorders: part I, basic principles, shift work and jet lag disorders. An American Academy of Sleep Medicine review Sleep, 2007.PMID 18041480
- [3]Sack RL, Auckley D, Auger RR, et al. Circadian rhythm sleep disorders: part II, advanced sleep phase disorder, delayed sleep phase disorder, free-running disorder, and irregular sleep-wake rhythm. An American Academy of Sleep Medicine review Sleep, 2007.PMID 18041481
- [4]Morgenthaler TI, Lee-Chiong T, Alessi C, et al. Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. An American Academy of Sleep Medicine report Sleep, 2007.PMID 18041479
- [5]Sletten TL, Magee M, Murray JM, et al. Efficacy of melatonin with behavioural sleep-wake scheduling for delayed sleep-wake phase disorder: A double-blind, randomised clinical trial PLoS Med, 2018.PMID 29912983
- [6]van Geijlswijk IM, Korzilius HP, Smits MG The use of exogenous melatonin in delayed sleep phase disorder: a meta-analysis Sleep, 2010.PMID 21120122
- [7]Mundey K, Benloucif S, Harsanyi K, et al. Phase-dependent treatment of delayed sleep phase syndrome with melatonin Sleep, 2005.PMID 16295212
- [8]Lockley SW, Dressman MA, Licamele L, et al. Tasimelteon for non-24-hour sleep-wake disorder in totally blind people (SET and RESET): two multicentre, randomised, double-masked, placebo-controlled phase 3 trials Lancet, 2015.PMID 26466871
- [9]Czeisler CA, Walsh JK, Roth T, et al. Modafinil for excessive sleepiness associated with shift-work sleep disorder N Engl J Med, 2005.PMID 16079371
- [10]Drake CL, Roehrs T, Richardson G, et al. Shift work sleep disorder: prevalence and consequences beyond that of symptomatic day workers Sleep, 2004.PMID 15683134
- [11]Wilson S, Anderson K, Baldwin D, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update J Psychopharmacol, 2019.PMID 31271339
- [12]Wilson SJ, Nutt DJ, Alford C, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders J Psychopharmacol, 2010.PMID 20813762
- [13]Sateia MJ International classification of sleep disorders-third edition: highlights and modifications Chest, 2014.PMID 25367475