Physical symptoms under forced-phase advance treatment in a patient with delayed sleep phase syndrome: A case report
Abstract
Abstract The physical symptoms that are observed with forced waking in patients with delayed sleep phase syndrome (DSPS) often prevent the successful treatment of patients. Better understanding of these symptoms will assist in providing appropriate treatment in such patients. Herein, a 19-year-old female patient with DSPS is described, in whom headache, fatigue, and dizziness were observed under forced-phase advance treatment. Statistical analysis showed that her headache was dependent on the therapeutic week, and her fatigue was dependent on the period of the day. There was no association between dizziness and either factor. Experience with this patient indicates that the fatigue observed with forced waking is related to the circadian system. This relationship should be explored for other physical symptoms as well.
INTRODUCTION
Physical symptoms including headache, fatigue, and dizziness are often observed upon awakening of patients with delayed sleep phase syndrome (DSPS) and sometimes increase with forced waking treatment.1 These difficulties often cause patients with DSPS to discontinue treatment. Thus, increased understanding of these symptoms will assist with appropriate therapeutic strategies. We report a patient with DSPS whose physical symptoms during forced waking treatment were determined to be associated with the circadian system.
CASE REPORT
A 19-year-old female presented with continuous fatigue, and she was subsequently diagnosed as having DSPS. Onset of symptoms was at age 15 years since the time she finished her high school examinations. Because of fatigue, she had to take a rest every day in the nurse’s office without participating in class. She consulted a physician and was diagnosed as having autonomic imbalance. Several drugs were tried, but all were ineffective. After the summer vacation, her rising time was delayed to 14.00 hours. It took her a total of 3 years to complete her first year of high school. When we saw her, we administered several hypnotics, stimulants, and antidepressants, but we failed to advance her sleep onset time. With phototherapy (3000 lx of bright light for 2 h beginning at 09.00 hours) we were able to advance her rising time. The treatment failed, however, because her bedtime was not advanced; she studied until midnight almost daily. The reduced time in bed exacerbated the daytime fatigue and disturbed the earlier rising. She was admitted to the psychiatric ward for entrainment to a reasonable sleep–wake schedule. Just after admission, she complained of headache, fatigue, and dizziness.
METHODS
After obtaining the patient’s informed consent, we advanced her rising time and bedtime at a rate of 1 h per week. Initially, her rising time was 09.30 hours. After 3 weeks of treatment, her rising time was advanced to 06.30 hours. An extra 2 weeks were needed to fix the sleep–wake schedule. During her hospital stay, a sleep-log, the time of daily physical symptoms (headache, fatigue, and dizziness), and core body temperature were recorded. The number of physical symptoms that she experienced was recorded for each of the following four time periods: (i) from rising time (RT) to the midpoint between RT and the time of acrophase of core body temperature (period 1); (ii) from the midpoint between RT and acrophase to the time of acrophase (period 2); (iii) from acrophase to the midpoint between acrophase and bedtime (BT) (period 3); and (iv) from the midpoint between acrophase and BT to BT (period 4). The physical symptoms were recorded weekly. The frequencies of symptoms were examined according to the treatment being trialled that week and by the circadian period. Statistical analysis was performed by one-way ANOVA.
RESULTS
The study’s results are shown in Table 1. Headache was observed mainly in periods 3 and 4 during the initial 2 weeks of admission. ANOVA showed a significant change in the number of headaches (F = 3.055, P < 0.01) from week to week; however, changes that were observed among the time periods did not reach significant levels (F = 3.238, P = 0.21). Fatigue was observed mainly in periods 1 and 2; the number of episodes of fatigue was observed mainly in periods 1 and 2 for the first 3 weeks, and the difference in the number of episodes per period differed statistically (F = 3.239, P = 0.02), although the number of episodes of fatigue did not differ statistically from week to week (F = 3.055, P = 0.6). Dizziness was observed only during the first week of therapy.
| Week 1 | Week 2 | Week 3 | Week 4 | Week 5 | |
|---|---|---|---|---|---|
| Headache | |||||
| Period I | 3 | 0 | 0 | 0 | 0 |
| Period II | 3 | 3 | 0 | 0 | 1 |
| Period III | 6 | 4 | 1 | 2 | 1 |
| Period IV | 4 | 5 | 2 | 2 | 0 |
| Fatigue | |||||
| Period I | 3 | 4 | 5 | 1 | 0 |
| Period II | 3 | 1 | 3 | 1 | 1 |
| Period III | 1 | 0 | 0 | 1 | 1 |
| Period IV | 0 | 0 | 0 | 0 | 0 |
| Dizziness | |||||
| Period I | 1 | 0 | 0 | 0 | 0 |
| Period II | 2 | 0 | 0 | 0 | 0 |
| Period III | 3 | 0 | 0 | 0 | 0 |
| Period IV | 3 | 0 | 1 | 0 | 0 |
- A significant difference for headache was observed in terms of the effect of the therapeutic treatment being trialled that particular week (one-way ANOVA, F = 3.055, P < 0.01), and a significant difference for fatigue was observed between periods (one-way ANOVA, F = 3.239, P < 0.02).
DISCUSSION
We examined the diurnal changes in physical symptoms in a female patient with DSPS under forced-phase advance treatment. Headache was observed mainly between the time of acrophase and bedtime. In contrast, fatigue was observed mainly between rising time and the time of acrophase. We found no evidence that dizziness was affected by the circadian rhythm.
