Curing DSPS and insomnia

From supermemo.guru
Jump to: navigation, search

This text is part of: "Science of sleep" by Piotr Wozniak (2017)

What is DSPS?

If you cannot live without an alarm clock to wake up in time for school or work, you might be suffering from a delayed sleep phase syndrome (DSPS). DSPS is also associated with problems with falling asleep if you try to keep an earlier bedtime. In other words, any cure for DSPS is also likely to solve the problem of sleep onset insomnia. If you go to a sleep expert with your DSPS problem, you will likely be prescribed melatonin or light therapy only to discover their limited impact on the quality of your sleep. If you are an insomniac, you may additionally be prescribed sleeping pills that might help you sleep without achieving the desired effect: a refreshed mind. This chapter should help you solve the problem. Using the properties of the human sleep control system, it can be proven mathematically that the problem of DSPS, and the associated insomnia, is always solvable, however, the solution does not need to imply the crispiest mind or the highest intellectual productivity. Moreover, many people will still fail due to lack of self-discipline! Where the modern world encroaches upon human biology, it is still possible to withstand the tide with the rules of reason. However, these imply a religious adherence to the decalogue of healthy living. Life shows that humans find all decalogues difficult to abide by!

Solution for insomnia, DSPS and N-24

This algorithm should help you in all the following cases:

  • if you are an insomniac, your body most likely tries to sleep in a different phase. If you fix the phase, you will fix the insomnia
  • if you are a DSPS case, esp. a long-term sufferer, you will be very skeptical of the algorithm. You need to give it at least a few weeks of well-disciplined try to see that your sleep cycle can be modified with the right tools
  • if you are a Non-24 and you believe there is no pattern to your sleep, you are most likely wrong. There are rare mutations that can totally mess up your sleep, but a more likely explanation is that you are a DSPS case who just introduces enough chaos into your sleep pattern to make it seem unpredictable. If you are otherwise healthy and if you try free running sleep, you will notice the pattern. For the pattern to emerge your "free" sleep must truly be free. No regulation. No artificial control! After that, you can try the algorithm presented below to see if you can show enough self-discipline to stabilize your cycle.

DSPS and lifestyle

Even though there are various genetic influences that play a role in DSPS, the problem is, for most people, largely a matter of lifestyle. I claim that due to the fact that a return to a farmer's lifestyle provides a guaranteed disappearance of the DSPS problem. Below, I have compiled a simple algorithm that should resolve DSPS in a vast majority of cases given sufficient self-discipline. Until now, I have been far more successful in showing people how to cope with DSPS using free running sleep than with the prescription listed below, which is a derivative of free running sleep with some limitations targeted at preventing a phase delay. The presented algorithm fails primarily because of one issue: violation of the rules! There are true hardcore DSPS cases with some psychiatric overtones or other health issues that might be particularly intractable. However, those should form a rare minority in the ever-increasing mass of people struggling with DSPS. Among young users of SuperMemo, I literally know dozens of cases. That mass now includes a countless population of insomniacs who have never heard of DSPS and never even arrived to the problem of phase shift due to the employment of the alarm clock. Weitzman hypothesized that a significant number of patients with sleep onset insomnia might be suffering from undiagnosed DSPS (Weitzman et al. 1981[1]). Now we know that hypothesis certainly holds true, which can be demonstrated by letting insomniacs free run their sleep. A significant phase delay may be observed within the first few days of such a release from the restrictions on the timing of sleep. At the same time, there is an accompanying and nearly instant disappearance of sleep-onset insomnia.

Implausible solutions

People who suffer from DSPS often resort to their own implausible solutions that include:

  • (poorly managed) free running sleep with an inevitable phase delays that ultimately result in sleeping through the day
  • skipping a night of sleep at a point when the bedtime reaches an outrageously late hour (i.e. usually after the dawn)
  • stabilization of the sleep pattern with medication (incl. melatonin) and artificial zeitgebers such as an alarm clock or a mom who pulls a sleepy student out from his or her bed for school
  • messy sleep that occurs at unpredictable hours with the loss of sense of the nighttime and long bouts of drowsiness, low energy, or poor health. This sleep pattern is often labeled Non-24 or N-24, however, in most cases it differs from DSPS only in the lack of self-discipline or knowledge needed to adhere to a natural sleep cycle, even if its period is longer than 24 hours

Only a well-managed free running sleep can produce healthy sleep in DSPS with a minimum risk of negative health outcomes. However, very few practitioners do really adhere to the rules of their own body clock as there are always excuses or inescapable reasons to violate the subjective night when it collides with daytime obligations or diversions. Sufferers of DSPS who try to "free run" their sleep for many years are at risk of messing up their sleep control system. I conclude that from the fact that their sleep patterns often become less and less regular[2], and the quality of their sleep often decreases. This effect would almost certainly be minimized if the sleep was truly free without medication, light therapy, artificial delays, or the use of the alarm clock. They may even falsely claim that their cycle started getting longer and longer, while it is the lifestyle demands that keep stretching the waking time. The culprit here, naturally, is not free running sleep per se, but various violations thereof that are inevitable due to a conflict of sleep with daytime activities.

Plausible solutions

If we exclude a healthy farmer's lifestyle and the renunciation of evening electricity, we arrive at only two reasonable lifestyle solutions to the DSPS problem:

  1. (well managed) free running sleep with phase delays, high creativity, high productivity, good health, and schedules that are nearly impossible to reconcile with the outside world
  2. stable 24h sleep cycle, with monastic self-discipline, good health, and slightly lower productivity

I write about free-running sleep throughout this article. I worship free sleep so much that I have been accused of labeling DSPS with the stamp of incurability. Here I would like to present a plausible algorithm for sustaining a 24h sleep pattern in DSPS with minimum artificial intervention into the fabric of sleep.

Is the battle for a 24-hour cycle worth having for those who have no work or family obligations? There is no good research to make comparisons. However, when in doubt, I always fall back on natural answers stemming from biological evolution. The biggest problem with non-24 cycles is that social life will always interfere. Nobody is hermetic to those influences. I have seen too many cases of free-running sleep falling apart for a minor temptation of an evening party with friends. Last but not least, we cannot discount the power of sunlight. It has been with us for millions of years of evolution. It is a personal bias, but jogging via woods in sunlight cannot be beat. Those who run in the evening or in the night miss out on a great blessing of nature. In the end, we do not need to choose between nature and modernity, my algorithm should provide a compromise.

Sticking with a 24-hours cycle has numerous advantages for DSPS sufferers. Life in harmony with the sun and nature might be the most enjoyable benefit

The algorithm: 24h lifestyle in DSPS

The only reasonable 24h solution to the problem of insomnia and DSPS is the change to the sleep phase. We can advance the sleep phase using evening measures (pulling the sleep backwards) and morning measures (pushing the sleep backwards). That takes care of the circadian component of sleep. In addition, all measures that boost homeostatic sleepiness in the evening are also welcome. However, without the circadian components those might actually compound insomnia. This is why only a comprehensive approach, as presented below, provides a solid chance for you to leave your DSPS and/or insomnia behind:

  • Determine the length of the waking day: Use SleepChart to determine the optimum length of your waking day. You may need a few weeks of free running sleep data to make a good estimate. If you cannot free run, and/or the procedure seems too complex, you could just make an educated guess. For example, if you believe you need 8 hours per night, in free running sleep it might be closer to 7 hours, and your optimum duration of waking would be 24-7=17 hours. However, due to the problem of possible insomnia, it makes sense to start from a slightly longer day and shorter sleep, e.g. from 17.5 hours of waking.
  • Determine the preferred waking time: This should be the same time every day! If you have to get up early only once per week, your entire cycle should be positioned to accommodate that early hour, or you will risk never-ending ripples in your circadian system and a possible failure. If the waking hour is late enough to ensure bright sunlight in the morning, your chances will increase greatly.
  • Religious bedtime: By adding your optimum length of the waking day to your preferred waking time, you will get your optimum bedtime that must be respected religiously. For example, if your preferred waking time is 9 am, in 17.5h waking day, your bedtime should be 9+17.5=26.5, i.e. 2:30 am. Respect for your bedtime is one of the keys to success. You will encounter many obstacles in the process. One of the most confusing ones is the change to your optimum bedtime depending on the contents of your day, your activities, your stress, weather, season, social interaction, and so on. For most people those changes are less than one hour. However, you are more likely to be in the wild variations category as this is one of the underlying problems in DSPS. Start adhering to your optimum bedtime as if your life depended on it. If you are very excited or stressed, and you are not sleepy at your bedtime, you can try again 20-30 min. later. You need to be sure you won't toss and turn, and that you do not wake up prematurely. If you see any signs of insomnia, you will know your bedtime comes too early and you allocated too much time for sleep. If you are very sleepy ahead of your bedtime and you have no doubts you will sleep like a log, go to sleep earlier. Your optimum bedtime is the guidance, your actual sleepiness is the ultimate deciding factor.
  • Start the algorithm. Ideally, you should start the algorithm at a time when your waking time precedes your desired waking time. Otherwise, you may need to temporarily resort to using an alarm clock. Each use of the alarm clock will add to your stress and anxieties related to early bedtime. If you have to use an alarm clock, and if you struggle with getting up in the morning, you should consider taking a full free running cycle with a daily delay of 20-40 min. until you arrive at getting up comfortably 2-3 hours before your chosen waking time. You could then try to re-start the algorithm.
  • Protected zone: As you suffer from DSPS, your primary objective is to prevent phase delay. This means that, in your last 2-4 waking hours, you need to avoid light, electricity, excitement, stress, intense sports, TV, computers, social interaction, e-mailing, web surfing, etc. If the presented algorithm does not work for you for a longer time, you may have to extend this "protected zone" up to a point where the resulting "inaction" results in more stress or frustration than it actually eliminates. Extending the protected zone beyond 2-3 hours of dark silence will probably be counterproductive. See for yourself. Remember, the protected zone is not a time for lying in bed! Unproductive time in bed will add to your stress, and if you fall asleep early, you can mess up your sleep on that night and actually delay the phase! Obviously there is a very limited range of activities you can do in the protected zone. I leave it up to your imagination. Perhaps moderate exercise in dim light. Or sex? Or walking and thinking? Seth Roberts swears by one-legged standing before sleep.
  • Morning light: One of the most powerful zeitgebers is light. If sunlight can stream into your room at the time when you should wake up, you might eliminate half of the difficulty in achieving a 24h balanced cycle. If this is impossible due to the season, or your early waking hour, or your living arrangements, you might consider using one of the commercial devices used in the "bright light therapy", esp. if you turn on the lights with the timer (if your device has no timer, you can use a timer that cuts off the supply of electricity for the night). Please be sure you read all the relevant safety instructions to prevent any long-term impact on your health.
  • Morning exercise: Another powerful zeitgeber is outdoor exercise. If possible, you should schedule that exercise early in the morning, or at least in the first 5 hours of the day. Morning exercise will affect your intellectual performance. You will most likely tire faster. However, this is also one of the factors why exercise should help you sleep better. Intense exercise late in the day may have the opposite effect and might delay your phase. However, some forms of exercise will not have this effect as the phase-shifting stimuli will be counterbalanced by the amplification of the homeostatic sleep drive and the "fasting effect" that will help you sleep early. Those evening exercises should be free of stress, injury, emotion, etc. Gentle calisthenics, yoga, or stretching would be an example of harmless evening exercise. Perhaps even body building, if not too exciting or strenuous. This late exercise would best be performed in dim light and in absence of other rousing stimuli. If you can swear that evening exercise helps you fall asleep faster, even if strenuous, remember that sleep itself has a phase-shifting power and can actually outweigh the opposite effect of adrenaline or locomotor activity. If you are not sure, experiment on your own.
  • Evening fasting: Unless you are a ravenous type that cannot sleep without a snack, give up meals in the last couple of hours of the day. As explained in the DMH section, food may have an additional impact on the positioning of your circadian cycle, and you do not want your brain to think that evening is an opportune time to get food. A healthy breakfast in the morning should have the opposite effect on the sleep phase and is always recommended by nutritionists even if sleep phase delays are not in the cards. Seth Roberts recommends skipping breakfast, but this should apply to those who suffer from early waking or ASPS, not for onset insomniacs or DSPS. Don't be discouraged by research that may claim that evening fasting will not affect your circadian cycle. For example, Sensi found that morning meals seem to favor carbohydrate metabolism, and meal timing, within the studied range, did not impact circadian cycle (Sensi and Capani 1987[3]). Fasting has many other added benefits, incl. slimmer waistline. Try it for yourself and see the impact of evening fasting on your sleep and health within a week! Read more: Fasting.
  • Adding pressure: If you keep failing by waking up too late, or not being sleepy at the desired bedtime, keep adding up pressure at both ends of your night sleep. More exercise in the morning, brighter lights in the morning, longer protected zone in the evening (free of stress, computers, lights, TV, etc.). The harder your case, the more you need to add. Choose a day free from other obligation for an exhaustive exercise marathon (which, for you, may be just a few hours of brisk walking), and spend the evening on undemanding relaxing activities that will help you advance your bedtime. You will need to figure out for yourself what exercise intensity ensures you do not wake up prematurely and what advance you can actually afford without making the situation worse.
  • Emergency: Melatonin: If your "protected zone" is stretched to the limit. You may consider an occasional pill of melatonin (e.g. 2 hours before your optimum bedtime). Remember that melatonin will affect your creativity and alertness, and should not be used on a regular basis. You could resort to melatonin on days when you are particularly wound up or when your waking time was particularly late. Remember also that large doses of melatonin may backfire. I guess you should not ever exceed 3 mg, however, you would better consult your sleep expert to make the final decision as to the dosage and timing. If you keep failing with the algorithm, you should rather increase the frequency of taking melatonin. You should not increase the dosage! Do not use marijuana as a "melatonin substitute"! If you think that your sleep and your brain performance do not suffer on MJ, you are wrong!
  • Emergency: Radio timer: As the algorithm is supposed to let you sleep without an alarm clock, you cannot expect to wake up at the same time every day. Actually, the larger your DSPS problem, the larger the variations you may expect. Achieving a very regular waking time is a matter of practice that some good sleepers develop over many years of repeated habits. However, if you regularly oversleep by more than an hour, or even still experience the dreaded phase shift, you may consider some occasional mild form of artificial sleep regulation such as turning on your alarm radio at the minimum sound level. Such a gentle alarm is only to help you wake early from the shallowest stages of sleep early in the morning. It should not deprive you of valuable REM sleep, and it should absolutely be set below the level that could rouse you from deep sleep. Your goal will always be to get rid of any interruption or intervention in the morning. Consider this only as a temporary measure that may help you in the initial adaptation period that is bound to include minor failures. You have probably heard of alarm clocks that read your sleep phase and help you minimize the pain of waking. I am not a great enthusiast of such solutions. The concept makes sense, however, it only minimizes the pain of possibly cutting a vital portion of your sleep. Set up an On-timer in your TV, on your favorite channel, at a minimum volume. If it fails to wake you up, you will know you need to work on other points of this algorithm. Trying to wake up for a specific hour is stressful enough to act as a substitute alarm clock that works for many people pretty well. Some scientists believe that ACTH secretion is set to ensure timely waking. I believe that this type of compacted sleep is still better than the one interrupted by alarm clock. At the very least, natural waking after short sleep definitely feels better than sleep interrupted at its deeper stages with an alarm clock. In conclusion, you should remember that your determination to succeed is also an important component of the algorithm. Determination may be unhealthy, it might affect your hormonal profile in sleep, it may weaken your immune system, however, balancing DSPS without giving up modern lifestyle will always have some residual negative health effects. Only a return to an ancient lifestyle would provide a hermetic solution.
  • Napping: A very controversial issue in DSPS is napping. Many experts will tell you that you should avoid napping altogether. I disagree. Naps may cause a phase shift if they are taken too late. Early naps, e.g. taken in the 6th hour of your waking day, will not have this effect. Naps will help you get your evening productivity, esp. if early waking in bright sunlight or early exercise aren't too good for your morning alertness. If you keep failing to achieve your 24h balanced cycle, you can gradually shift your naps to earlier hours. This will reduce their length and their efficiency, however, this will also minimize their phase shifting effect. Only if all other suggestions fail, you should drop napping altogether. If you bemoan the loss of mental acuity, remember that we have not evolved to be alert and productive all day. 100% sharp mind is only our desire that has, among others, contributed to the DSPS problem in the first place. See: Best time for napping
  • Caffeine: Sleep experts will often tell you to wean yourself off caffeine. However, I beg to disagree. A cup of early morning coffee or tea will likely have a beneficial effect. Its impact on the homeostatic sleep drive will increase your alertness, which on its own has a phase shifting power. Early caffeine will help you advance your phase! You should avoid caffeine in the later parts of the day though. Before sleep you will already be in mild withdrawal, which, theoretically, should boost your homeostatic sleep drive and allow for a slightly earlier bedtime. This way, caffeine may help you achieve phase advances at both ends of your night sleep.
  • Alcohol: Drinking alcohol before sleep may have disastrous effects on your effort to balance the cycle. One of your major enemies will be premature waking after premature bedtime. Alcohol will increase that risk manifold. Premature awakening will result in insomnia, in powerful phase shifts, in difficulty in waking, in sleep deprivation, and in an early collapse of all your efforts! Western culture is generally tolerant of moderate drinking in the evening as opposed to the morning when we are supposed to be productive. I think this tolerance should change. As much as early drinking undermines the thinking, evening alcohol might do even more damage by destroying sleep.
  • Stress: Stress can ruin all efforts presented in this algorithm. Wherever possible, try to pile up stress in the morning, and let the second half of the day be always free from worries and anxieties. Naturally, stress that lasts for days is a general enemy of healthy and productive living. If this is your problem, please have a peek at the stress section of this article to see if you can find any useful hints there.
  • Myopia: If you are shortsighted, you should consider getting a correct prescription. Some theories of myopia favor underprescription (Rehm 1981[4]), however, you will also find evidence to the contrary (Coghlan and Le Page 2002[5]). If you lean to the underprescription side, consider using the correct prescription only in the morning. Only the first 2-4 hours matter. You may recall from your physics class that the amount of light reaching the retina will actually be reduced with the increase to the focal power. However, well-focused light will be more likely to produce strong maxima with a phase-shifting power. Analogously, you might also consider using dimmed spectacles in the evening. Naturally, these are not recommended for "close world" applications (such as reading the computer screen) as these might accelerate the progression of myopia.
  • Computer screen: There are computer screen filters and applications that can help you filter phase-shifting light frequencies that can dim your monitor in the late evening. I hear from users of those applications that they are helpful in their DSPS battles. As always there is a risk this might be a placebo effect. However, the cost of trying isn't high.
  • Difficulties: If you keep experiencing phase shifts, move your siesta to an earlier time, or give it up altogether (at last until you regain the balance). Use emergency measures (melatonin, radio news) only as a last resort. If those last resort solutions keep being necessary, it may appear that a shifting free running sleep cycle does less damage than trying to stick to a "healthy" stable rhythm. Review all the recommendations on this list. Did you employ them all? Did you show self-discipline? If so, it should work in most cases. All the failures I have seen came from rather flimsy excuses and minor violations. All the success I have seen came from treating sleep regimen as a religious routine. If all else fails, write to me with your story.
  • Target: In the initial period, lack of experience, misalignment of sleep control variables, sleep debt, lack of conviction, etc. will make it a bit harder to stick to the presented algorithm. This is particularly difficult for those who do not need to get up early for work. Their mind might vacillate. Is early rising worth the effort? It may therefore be psychologically helpful to begin one's sleep reform 3-4 weeks before an important event that requires early rising. The thought of participating in an important event with a fresh mind will increase the motivation to adhere to the rules.
  • Creativity dip: Once the presented algorithm works for you, you may be disappointed to notice that your creativity isn't as rampant as on those weekends when you get your solid 8 hours of sleep, or when you go to sleep at 5 am (whichever is your cup of tea). That's the unavoidable cost of sleep phase resetting and phase advance measures. We have evolved to live 24h lives with a primary concern for surviving, getting food, etc. Crisp or creative mind isn't that important when you are to run away from a predator. When you meet a lion on a street, you are bound to be in your top shape for flight. The degree of your creative decline may be proportional to the degree of the original problem as well as the length of the period in which you tinkered with your sleep control systems using the alarm clock, sleeping pills and other brain health enemies.
  • It works! Remember that every healthy individual can stick to a 24 hour cycle on a farmer's lifestyle. Some disabilities, e.g. blindness, may make it impossible, but these should only be an exception to the rule. At worst you could try out the farmer's lifestyle to realize that it solves your sleep problem, and then try to reconcile that extreme with the presented algorithm. There is an optimum for you somewhere in-between and it does not need to be unhealthy.
  • Ultimate cure? The title of this chapter should not make you think that you can cure DSPS for good. It is always there. You can temper your response to the temptations of modern life and return to a balanced sleep pattern as your reward. Your lifestyle is your cure.

Outcome: Balanced 24h sleep cycle!

If you use SleepChart, you can see the impact of the presented algorithm in the circadian graph. Exemplary outcome of the application of the presented algorithm is presented below:

Perfectly balanced 24h cycle in DSPS

Figure: Perfectly balanced 24h cycle in DSPS:

  • the green line determines the conditions for the balanced 24 hour cycle (waking time + sleep time = 24 hours)
  • the nap is taken in the 7th hour from arising (the left blue peak) and lasts 1.2 hours (the left purple vertical line). The nap is used to partly compensate for a short nighttime sleep
  • the optimum length of the waking day is 18.3 hours and is determined by the crossing of the green line that determines the 24h sleep-wake cycle and the average sleep time depicted by the red curve. Shorter day is possible but entails a risk of sleep-onset insomnia. Longer day will result in phase delays (the area where the red line is located above the green line)
  • the optimum length of the night sleep is 5.7 hour (horizontal orange line).
  • the cycle implies 5.7 hours of sleep in the night and nearly 6.9 hours of total sleep, which might be equivalent to 9 hours of nighttime sleep in monophasic sleep (see: Optimum nap duration)

Summary: Curing DSPS

In the presented algorithm, you try to stick to your optimum bedtime and waking time every day. You establish a protected zone in the evening to favor phase advance (minimum light, computers, stress, excitement, etc.). You wake up to bright sunlight and use morning exercise to advance the phase in the morning. You ingest caffeine only in the morning. You avoid alcohol in the evening. If you nap, you nap early. If your phase keeps shifting, you add more light and exercise in the morning. You also extend your protected zone in the evening. In an emergency, when you fear falling out of synch, you could occasionally use melatonin in the evening or delicate sounds in the morning as the minimum effective departure from the free running sleep principle.

References

  1. Weitzman E.D., MD, Czeisler C.A., MD, PhD, Coleman R.M., PhD, Spielman A.J., PhD, Zimmerman J.C., PhD, Dement W., MD, PhD, and Pollak C.P., MD, "Delayed sleep phase syndrome. A chronobiological disorder with sleep-onset insomnia," Archives of General Psychiatry / Volume 38 / Issue 7 (July 1981): 737–746, doi: 10.1001/archpsyc.1981.01780320017001]
  2. LivingWithN24, "Charting the course of N24," DSPS, a sleep disorder (October 27, 2010)
  3. Sergio Sensi and Fabio Capani, "Chronobiological Aspects of Weight Loss in Obesity: Effects of Different Meal Timing Regimens," Chronobiology International / Volume 4 / Issue 2 (1987): 251-261
  4. Rehm D.S., The Myopia Myth: The Truth About Nearsightedness and How to Prevent It," Ligonier: International Myopia Prevention Association, 1981
  5. Coghlan A. and Le Page M., "Eye correction is seriously short sighted," New Scientist (November 20, 2002)