What Can You Do When You're Too Tired, Too Early?

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We often read about, or may know someone—often a high school or college student—who stays up way too late and then has a very hard time getting up in the morning. When bedtimes and wake times both get very late, and a person is not able to fall asleep until, say, 2 a.m., we refer to this as delayed sleep phase syndrome. This is not a rare problem—it afflicts as much as seven percent of the adolescent and young adult population. Numerous articles appear in the sleep literature about this disorder.

But what about those who have the opposite problem? What about people who just can’t stay up until, say, 10 p.m.—a typical bedtime? These individuals have advanced sleep phase disorder, a group that constitutes up to one percent of middle-aged people. And we see far fewer articles about this problem.

Collectively, both of these sleep problems are known as circadian rhythm disorders and are related to the natural 24-hour pattern of wake and sleep we experience on a daily basis. The circadian system prepares us for the day and allows the body to be in optimal condition at different times of day. For example, as the sky darkens and night approaches, the circadian system helps prepare the body for the onset of sleep. In a similar way, when dawn begins to brighten the sky and morning approaches, sleep begins to shift increasingly from the deep stages to dreaming. Our sleep becomes increasingly light so that we can easily awaken and be prepared to start the day.

Advanced sleep phase syndrome is essentially the opposite of delayed sleep phase syndrome. Those who experience it find that it becomes difficult to engage in evening activity because they have a strong propensity to fall asleep quite early. They then awaken at around 3 a.m. or even earlier. While delayed sleep phase syndrome is most often observed in young people, advanced sleep phase syndrome is more likely to occur in older individuals. Along with the unusually early bedtime, other circadian rhythms are also affected, as in the daily changes in core body temperature or the release of certain hormones. (Although using melatonin to encourage sleep is considered controversial by many in the sleep field, there is evidence that it can help restore normal circadian functioning when one uses it properly.)

The outstanding features of advanced sleep phase disorder are habitual and involuntary sleep and wake times that are generally more than three hours earlier than societal norms sanction. It appears that the sleep itself is normal relative to the age of the individual, just shifted earlier than that which is typical for a majority of society. You may know older individuals who complain of an overwhelming need to sleep starting in the late afternoon or early evening. This can significantly reduce a person's ability to engage in typical evening activities such as cleaning up the kitchen, reading a book, chatting with family, or watching TV. Conversely, such people find it very difficult to sleep beyond 2 a.m. to 5 a.m. in the morning. This can disrupt daily activities, as it is often not possible to engage in meaningful job-related or social activities that early in the morning—and hours may go by during which the person is wide awake but has nothing to do. Then later in the day, people with advanced sleep phase syndrome may work very hard to force themselves to stay awake because of various work or social responsibilities. This pattern can easily lead to having insufficient sleep and increased daytime drowsiness. Because early-morning awakening has been associated with depression, a patient reporting very early waking, fatigue, and low mood could easily be misdiagnosed with clinical depression, leading to inappropriate (and ineffective) treatment.

In some ways, it is easier to cope with advanced sleep phase disorder and going to bed earlier at night, than it is to deal with delayed sleep phase disorder and staying up until the wee hours of the morning (and then needing to get up early to go to work or school). While I have seen a number of patients with advanced sleep phase syndrome over the years, in my experience, it is much less common than delayed sleep phase syndrome. Frequency does increase with age, and there is no reported difference in prevalence between men and women.

The cause of advanced sleep phase disorder is not fully understood. It may be that predisposed individuals are particularly sensitive to the effects of light on their circadian rhythm. It is also possible that the length of an individual’s circadian rhythm is important. Most people have a circadian rhythm somewhat longer than 24 hours. The clock then resets due to light, activity, social interaction, and eating on a daily basis. Individuals who develop advanced sleep phase syndrome may have a circadian rhythm that is shorter than 24 hours. It appears that genetic factors are significant in the development of this disorder as well.

While some people may have a propensity for going to bed early and getting up early, as is the case with “larks,” a diagnosis of advanced sleep phase disorder is only made when there is a chronic or recurrent complaint of going to bed and getting up too early that results in impairment of functioning in social, occupational, or other important realms. We must also point out that other medical or psychological disorders can produce similar symptoms: For example, the early-morning awakening noted above may be associated with a major depressive disorder.

Treatment for circadian rhythm disorders can be challenging. One intervention that is plausible if the patient has a flexible schedule is called chronotherapy. Implementation involves having the person go to bed and get up three hours earlier every two days until they reach the desired bedtime. While this can be helpful, the potential for rapid relapse exists, and it requires constant effort to maintain the new sleep schedule. Another technique is bright light therapy, which employs exposure to a special bright light from 7 to 9 p.m. This therapy should only take place with the supervision of a sleep specialist—if not used properly it could cause further disruption of circadian rhythm and could trigger hypomanic episodes in people with bipolar disorder. Another possible treatment is to take melatonin upon waking up in the morning. It is theorized that this could allow for a later bedtime that evening, just as melatonin used in the afternoon can cause an advanced to an earlier time for people with delayed sleep phase syndrome. This is not a proven method and could cause problems due to the sedating effect of melatonin—which would be unhelpful in the morning.

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If you are having difficulty staying awake into the evening, and waking up much earlier than desired, you may have an advanced sleep phase disorder. If a circadian rhythm disorder is resulting in damage to your work or social activities, or in increased daytime sleepiness due to an insufficient amount of sleep, arrange an evaluation with a sleep professional rather than experimenting with unproven treatments or struggling to get through your day. It may result in you being alert and up and about when the sun shines, and joining your peers in the Land of Nod when the stars twinkle in the nighttime sky.