Understanding Delayed Sleep Phase Syndrome: Recognizing Signs, Exploring the ADHD Connection, and Approaches to Treatment

A live webinar is scheduled for the 16th of January titled "How Seasonal Affective Disorder Uniquely Affects People with ADHD".

Often, sleep disorders and related issues coexist with ADHD, but the connection between ADHD and delayed sleep phase syndrome (DSPS), a type of circadian rhythm sleep disorder, is often overlooked. Also, DSPS is frequently found in individuals with ADHD, but it is commonly unidentified, and it's usually mistaken for poor sleep hygiene or another sleep disorder.

When DSPS is not diagnosed properly, it has adverse effects on ADHD symptoms and significantly disrupts a person's quality of life. Accurately identifying DSPS, a treatable condition, is crucial since traditional sleep management approaches often fall short when addressing this sleep disorder.

DSPS is defined by considerable difficulties in falling asleep and waking up at the socially accepted times. DSPS interferes with the internal body clock, causing people to naturally sleep and wake up several hours later (usually more than two hours) than the majority of people.

The American Academy of Sleep Medicine2 has pointed out the following symptoms and characteristics of DSPS.

A symptom examination: Could you be suffering from Delayed Sleep Phase Syndrome?

Often, individuals with DSPS, who feel completely awake and invigorated during the normal sleep hours, will stay up very late conducting various activities, causing them to be more exposed to artificial light which further interferes with the circadian rhythm. Usually, they go to bed in the early hours of the morning when they finally feel sleepy.

Contrarily, other individuals with DSPS will try to sleep at socially accepted times only to lay awake in the dark for hours awaiting sleep. Being awake is not due to anxiety or a mind that can't switch off, but because their bodies and brains are physiologically not prepared for sleep.

The outcome for those with DSPS tends to be a short sleep window as normal hours' work and school commitments await them in the morning. Consequently, waking up is a big struggle for these individuals. It's common for them to rely on many alarms or even other people to wake them up. Upon waking up, these individuals, sleep-deprived with their brains still half-asleep, feel terrible.

Nonetheless, individuals with DSPS often wake up feeling refreshed and ready to tackle the day when they get a chance to sleep in during weekends and vacations. Whether aware or not that they have DSPS, some people structure their lives around their delayed sleep cycle, which works out if they have a flexible work or study schedule. However, a late sleep cycle more often than not leads to significant impairments. Those who adopt a completely reversed sleep cycle, sleeping during the day and being awake all night, frequently experience additional mental health issues and functional impairments.

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As practising clinical psychologists working with adult ADHD patients, we are amazed by the frequency of DSPS cases among our clients. Yet, many of these clients have never heard of DSPS. Many of these individuals have sought help with their sleep-wake challenges, only to be misdiagnosed and receive inappropriate treatment strategies such as sleeping pills. Consequently, these clients continue experiencing significant sleep challenges that affect their overall functioning.

From our experience, DSPS is often confused with bedtime procrastination or willingly delaying bedtime in favour of other activities like browsing social media or binge-watching TV series. Activities which keep the brain alert. With ADHD associated with dopamine and self-regulation challenges, it's easy to attribute bedtime procrastination as the predominant cause of sleep and wake-up difficulties at normal hours. The situation is exacerbated by ADHD-associated time-management and organisation challenges making it harder to maintain reasonable bedtime and wake-up hours.

However, DSPS can coexist with bedtime procrastination. The key distinction being that individuals simply engaging in bedtime procrastination can fall asleep at socially acceptable hours but choose not to do so. They likely feel sleepy while engaging in bedtime procrastination or readily fall asleep once the stimuli keeping them awake is removed. In contrast, individuals with DSPS cannot fall asleep at socially acceptable hours, even under ideal sleep conditions, due to differences in their circadian rhythm.

DSPS often gets confused with insomnia due to their apparent similarities. Although insomnia, a sleep disorder marked by difficulty in falling or staying asleep and/or poor quality of sleep can occur concurrently with DSPS, it is also common among those with ADHD.

While those with insomnia state difficulties in initiating sleep, DSPS sufferers struggle to go to sleep at usual, socially accepted times. Interestingly, falling asleep isn't a problem for DSPS sufferers when it is in line with their internal body clock, even if it means sleeping several hours later than normal. Unlike insomnia sufferers, DSPS individuals don't usually have issues in maintaining sleep.

It's important to talk to a doctor or sleep specialist if you suspect DSPS as the cause of your sleep disruptions. A proper diagnosis is necessary because of the unique physiological aspects of DSPS which need direct treatment. To manage DSPS effectively, one requires an understanding of circadian physiology since treatments for this sleep disorder primarily focus on the internal clock.

Typical solutions for sleeping difficulties-like those suggested for insomnia, including good sleep hygiene, sleep restriction, and stimulus control strategies, as well as sedative medication, are generally not effective for people with DSPS.

A predictable 24-hour cycle is followed by numerous bodily and behavioral processes-ranging from sleepiness and alertness to fluctuations in core body temperature. Ideally, a person's internal clock resets each morning with light exposure. Without the right amount of morning light, the sleep-wake cycle may slowly drift into later hours each day, uncoupling from the day-night cycle.

Circadian rhythm is also influenced by darkness, which initiates the release of melatonin, a hormone that lowers core body temperature and readies the body for sleep. Evening bright light exposure, even at low levels, inhibits melatonin production, thereby delaying sleep and slowing circadian rhythm. Thus, the treatment of DSPS strongly relies on the proper timing of exposure to light and darkness.

Light therapy for DSPS involves increasing exposure to bright light upon waking and reducing exposure to light as much as possible before bedtime, along with gradually adjusting sleep-wake times to regulate the internal clock.

Under this approach, exposure to bright light should happen within two hours of natural waking time and last for at least thirty minutes. Unfiltered daylight exposure is the best; even the light exposure on a cloudy day outperforms indoor lighting, which is generally not bright enough to affect the circadian rhythm. Morning walks for light exposure are excellent for strengthening and synchronizing the circadian rhythm, but light exposure gadgets like wearable LED light visors can also be useful. Eye strain and headaches are potential side effects of light therapy.

Significant note: Delaying light exposure is necessary if you wake up within six hours of going to sleep (either naturally or by force) to avoid further delaying your body clock. The core body temperature falls to its lowest point about six hours after sleep begins. Light exposure after this six-hour point encourages earlier sleep onset and wake time. Opposite effects are caused by light exposure prior to this point.

If your normal bedtime is around 3 a.m., exposure to light should not happen until after 9 a.m. If you cannot avoid getting up before 9 a.m., avoid sunlight (keep the blinds closed) and lower or switch off artificial lights. If outside activity before 9 a.m. is unavoidable, wear sunglasses and a hat to protect yourself from direct sunlight.

Combining light therapy with avoiding light exposure before and during sleep helps in preventing melatonin suppression. Reducing the lights and refraining from using screens two hours before sleep aids natural melatonin production. If this is not workable, you can install a blue light filter on your device or wear glasses with orange lenses. Use a sleep mask or blackout curtains to create a dark sleeping environment.

The final element of light therapy involves gradually moving the bedtime and rise time 15 minutes earlier each day. The aim is to adjust your body clock to sleep and wake up at normal times. It might take a few weeks to reach desired sleep and wake-up times. From this point onwards, a relaxed maintenance routine is important, including fairly consistent wake-up times and morning light exposure times on most days.

Talk to your doctor about taking melatonin to manage DSPS, as carefully timed melatonin administration can aid in shifting circadian rhythm.4 For optimal circadian shifting, take melatonin about six hours before your natural sleep onset. For example, if you typically fall asleep at around 3 a.m., take a 3 mg dose of melatonin at about 9 p.m. As your sleep phase shifts earlier, adjust the timing of melatonin intake accordingly. Once you’ve reached your desired sleep time, help maintain it by taking a lower dose (1-2 mg) of melatonin two hours before bedtime. Be sure to discuss any changes to your melatonin use with your health provider.

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