Chronotherapy PDF

Chronotherapy
Mateo González Agudelo

Resident of 3rd year, Aerospace Medicine
National University of Colombia
Introduction
Circadian rhythm sleep disorders -- defined in
psychiatric classification systems.
• DSM IV
• delayed sleep phase type sleep disorder (DSPTSD)
• shift work type sleep disorder
• jet lag type sleep disorder
• undefined type.
Sack, Robert. Treatment of cricadian Rhythm Sleep Disorders. Handbook of Slee Disorders. Second Edition.
Frecuencia
alta
0.5 ms- 30
min <20 horas
Frecuenci
a media
30 min -6
dias
Frecuencia >24 horas
baja
>6 dias Circamareal Circalunar circaanual
Regulation of sleep-wake rhythm
• Sleep and wake: Modulation of the thalamus
and the cortex by the brain stem.
• Cholinergic, noradrenergic and serotoninergic
nucleus.
• Direct effects on cortical function.
Homeostatic process S and
the circadian process C
• Homeostatic process S: rise of

sleep propensity during waking and
its dissipation during sleep
• Circadian process C: is
independent.
Alternation of periods with high and
low sleep propensity
Circadian rhythm sleep disorders (CRSDs)
• Homeostatic and circadian mechanisms (sleep-wake)

• synchronized with the 24-hour solar daynight cycle
Misalignment of endogenous circadian rhythms

• desired (or required) time for sleep and wakefulness
The opponent process model of sleep-wake regulation
by Edgar et al.
Level of alertness results from of

the opposing forces of sleep
drive and an alerting process.
The opponent process model of sleep
regulation in a night shift worker
Principles of Treatment
Circadian phase shifting
• “resetting the body clock”

• Timed Light Exposure
Prescribed sleep scheduling
• Chronotherapy
Pharmacotherapy
• counteracting the symptoms of sleepiness and insomnia

Sleep Scheduling
Chronotherapy  Sleep schedule treatment of delayed sleep
phase type sleep disorder (DSPD )
• Human circadian period is usually longer than 24 hours

• Might be exceptionally long in patients with DSPD.
Chronotherapy
• Timing of sleep is intentionally delayed several hours
• If relapse  The procedure is repeated.
Delayed Sleep Phase Type D.
Circadian rhythm sleep disorder
• Prevalence of
• learning disorders: 19.3%
• personality disorders: 12- 22.4%.
DSPTS Identified in 1979 by Weitzman et al.

• Also manifests in the measurement of endogenous circadian
rhythms
• P  adolescents: 7%. Adults: 0.17%-0.7%
• Begins between late childhood and early adulthood  Academic
failure
Gökben Hizli F, et Al. [Delayed sleep phase type sleep disorder and chronotherapy]. Turk Psikiyatri Derg. 2009;20(2):183-187.
Delayed Sleep Phase Type D. and differences with others CRSDs
Chronically sleep deprived and experience drowsiness during the daytime
while they are wakeful during the night.
• Co-occur with depressive symptoms.
• Depression is the most frequent comorbid
• The increase in diurnal sleep time and the decrease in exposure to daylight may
trigger depression, especially seasonal depression.
Unable to conform to conventional work

schedules or other social demands.
Gökben Hizli F, et Al. [Delayed sleep phase type sleep disorder and chronotherapy]. Turk Psikiyatri Derg. 2009;20(2):183-187.
• 1) Impaired functionality in social and occupational domains

• 2) Unsuccessful attempts to regulate sleep-wake times
• 3) Difficulty maintaining a state of wakefulness in the morning.
Widely used treatment options:

Phototherapy or bright light therapy
Melatonin administration Chronotherapy
Dagan Y (2002) Circadian rhythm sleep disorders in psychiatry. Isr J Psychiatry Relat Sci, 39: 19-27.
Prescribed Sleep Schedule
Systematically delaying sleep times by

about three hours per day around the
clock.
• Requires a high level of patient
compliance.
• Rational and can be quite effective
• No controlled studies
Recommendation:
• Prescribe a sleep schedule
• In conjunction with treatments that
promote circadian phase advances
Prescribed Sleep Schedule
• Delay sleep and wake

times by 3 hours each day.
• Strictly follow the protocol
• Fix her sleep-wake chart

after 1 week and remained
on that time schedule.
Dagan Y (2002) Circadian rhythm sleep disorders in psychiatry. Isr J Psychiatry Relat Sci, 39: 19-27.
Combination Treatment
Evening melatonin and morning

bright light are often prescribed in
conjunction with chronotherapy.
Large circadian “phase jumps” are

difficult to achieve
Mateo González Agudelo
Resident of 3rd year, Aerospace Medicine
National University of Colombia
Introduction
Sleep loss and circadian misalignment
• implicated in numerous incidents and accidents

Conducted a study of
short-haul commercial
Many occupation: in non-traditional daytime work
airline operations using a
• variable daily start and end times controlled shift design…
• requiring high workload
Early starts and late finishes  how work start time and
workload affect sleep
• not be classified as night work duration and timing,
alertness, cognitive
performance, and circadian
Shifts have the capacity to cause circadian disruption phase
• high prevalence of sleep deficiency
Methods: Participants and Protocol
• All pilots working for a single airline.
Schedule:
• Cycle worked a baseline block (baseline):
• 5 days of short work shifts
• Starting in the mid-morning
• 2 flight segments. (2 hrs)
**4 days off.
• 5 early starts (early)
**3 days off
• 5 midday starts (midday) --- Included more flight segments and longer work shifts.
**3 days off
• 5 late duties (late) -- to start in the late afternoon followed.
** 4 days off
Methods: Study Protocol
• Ipod:
• study questionnaires
• daily sleep diary
• study schedule and
• iPod version of the psychomotor vigilance task (PVT)
• The morning sleep diary also included: Samn Perelli fatigue scale and a
Sleep quality rating
• Participants wore an Actiwatch

• Sleep latency
• Sleep duration
• Wake After Sleep Onset (WASO)
• Sleep efficiency
• On rest days  to complete the PVT three times every day
**3 days off
5 midday starts (midday)
5 days of short work shifts (baseline)
**3 days off

**4 days off. 5 late duties (late
5 midday starts (early)
** 4 days off
Results
• 44 pilots (4 female)
• Aged 30.8 +- 7.1 years
Results: Impact of schedule start time on sleep
Study participants attempted to initiate sleep at significantly
different times during each of the study blocks relative to their
baseline bedtime
Results: Impact of schedule start time on sleep
• Sleep efficiency was not significantly different for any work schedule type
relative to baseline (early P = 0.34, midday P = 0.55, late P = 0.12)
• Wake after sleep onset (WASO) was not significant for midday (P = 0.12) or
late work shifts (P = 0.71) relative to baseline
• There was significantly more WASO during the sleep preceding early work
shifts compared to baseline (P = 0.03).
Results: Impact of schedule start time on performance
• Statistically significant increase in mean reaction time (RT) and lapses (> 500 m sg)
• Decrease in transformed reaction time between the baseline condition and each
of the more challenging flight schedules
Results: Impact of schedule
start time on performance
• During the early and late schedules (ꓳ & Δ), PVT

reaction time and lapses increased significantly
from the beginning to the end of each rotation.
• Response speed decreased.

Discussion
Our study confirms that sleep duration and reaction time are affected by schedule
type even when work start times are scheduled to occur during the day.
Early and late starts elicited a progressive decline in sleep duration
We observed reduced sleep quality and quantity on early starts that

remained reduced low for the duration of the early work shifts.
Conclusion
Found evidence of performance degradation on the late shift

rotation relative to baseline that progressively declined by day.
Midday work shifts, which included higher workload with many flight sectors,
was associated with performance impairment in comparison to baseline, but
no difference in sleep duration.

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Chronotherapy

Mateo González Agudelo

• Homeostatic process S: rise of

• Homeostatic and circadian mechanisms (sleep-wake)

Misalignment of endogenous circadian rhythms

Level of alertness results from of

• “resetting the body clock”

Prescribed sleep scheduling

• counteracting the symptoms of sleepiness and insomnia

• Human circadian period is usually longer than 24 hours

DSPTS Identified in 1979 by Weitzman et al.

Unable to conform to conventional work

• 1) Impaired functionality in social and occupational domains

Widely used treatment options:

Systematically delaying sleep times by

• Delay sleep and wake

• Strictly follow the protocol

• Fix her sleep-wake chart

Evening melatonin and morning

Large circadian “phase jumps” are

• implicated in numerous incidents and accidents

• Participants wore an Actiwatch

**3 days off

5 midday starts (early)

• During the early and late schedules (ꓳ & Δ), PVT

• Response speed decreased.

Early and late starts elicited a progressive decline in sleep duration

We observed reduced sleep quality and quantity on early starts that

Found evidence of performance degradation on the late shift

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