Dr. Colin M Shapiro MBBCh, PhD, MRC Psych. FRCP(C) Professor, Department of Psychiatry and Opthalmology University of Toronto Director, Sleep and Alertness Clinic Youthdale Child & Adolescent Sleep Centre
Adam and Oswald: Clinical Science 1983, 65, 561 In nocturnal animals peak rates of RNA and protein synthesis, RNA and protein content of cells, number of cells and growth rates occur at the time when sleep predominates i.e., during the light period. Activity Period Sleeping Period * * * * * * * * * * 1800h 2400h 0600h 1200h 1800h * Each star represents a published report * * *
16 14 12 10 8 6 4 2 LIFE - Cycle and Sleep Composition of Sleep 50% 26% 25% 19% 24% 53% 1% 2% REM DEEP LIGHT WAKE 25% 11% 61% 3% 18% 5% 62% 5% Newborn 16 hrs. avg. Young Adult 8 hrs. avg. Adult 7 hrs. avg. Elderly 6 hrs. avg.
INSOMNIA Difficulty Falling asleep Can t Stay asleep (keep waking up) Wake up too Early in the morning Sleep is not Refreshing Can affect up to as many as 1 in 5 teens Signs: always Fatigued; Drinking too much Caffeine; Inattention; Irritable; Lack of Get-up and Go
Melatonin secreted by the pineal gland melatonin is produced to help our bodies regulate our sleep-wake cycles Darkness stimulates the release of melatonin and light suppresses its activity melatonin cycles are disrupted when we are exposed to excessive light in the evening or too little light during the daytime
DELAYED SLEEP PHASE DISORDER (DSPD) Difficulty with sleep onset at desired time Once initiated, sleep is normal Most common CRSD referral Population data lacking Population estimates of prevalence of 0.17 0.25% Prevalence increases to >15% amongst adolescents Insomniacs: 10% Positive family history
Sleepiness in Seattle & Toronto You are here Your body clock is in Vancouver
TREATMENT OPTIONS Melatonin Bright Light Therapy Chronotherapy + Behavioural Strategies
DELAYED SLEEP PHASE DISORDER (DSPD) Normal Sleep Phase DSPD 19 21 Midnight 3 6 9 Noon Phase ADVANCE Melatonin pulls sleep time forward Light pushes it away/forward
LIGHT APPLICATION IN CHRONOTHERAPY FOR EXTREMELY DELAYED DSPD Chronotherapy Light Application
BEHAVIOURAL STRATEGIES Lifestyle changes Sleep hygiene guidelines Changing attitude
Rahman, Kayumov,Casper & Shapiro Patient with phase delay are more likely to develop depression! 2010
School-related Symptoms of Youth Depression Poor performance in school, truancy, tardiness Withdrawal from school activities/peer groups Lack of enthusiasm, energy or motivation Globalized anger and rage Overreaction to criticism, increased self-criticism Indecision, lack of concentration or forgetfulness Restlessness and agitation Problems with authority Suicidal thoughts or actions (e.g., cleaning out locker, giving away items)
Fear of failure social rejection bodily sickness bullying or abuse childhood memories thoughts of a better life separation with family worries about the future
This booklet was distributed to parents, school boards, family doctors, group practice and social workers. Response was positive and helped families in particular to accept the diagnosis and initiate treatment specifically.
Parents and health professionals were able to recognize the behavior in the children after reading this booklet. This educational tool also helped in the early recognition, detection and assessment of depression in children and teenagers at the sleep clinic.
CIRCADIAN PHASE MARKERS Active investigation into markers of circadian phase in humans Two currently utilized markers Core body temperature Dim light melatonin onset (DLMO)
Melatonin (pg/ml) DIM LIGHT MELATONIN SECRETION ONSET (DLMO) Time of Day Increase in levels begin between 6:00 pm & 9:30 pm (DLMO) Levels peak approximately 3:00 am & begin to decrease Lowest levels just before awakening
Melatonin pg/ml DIM LIGHT MELATONIN ONSET: NORMAL Time
Melatonin pg/ml DSPD: DLMO (DIM LIGHT MELATONIN ONSET) TEST Time
Melatonin pg/ml DLMO: NORMAL VS DSPD DSPD Normal Time
Melatonin pg/ml Melatonin DLMO MELATONIN DSPD Approx 5 hours DLMO:
BRIGHT LIGHT THERAPY HABITUAL WAKE UP TIME (~11:00 a.m.)
See also Ottawa slides on ADHD and Tourette s Syndrome