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Circadian Rhythm Sleep Disorder Due to Drug or Substance

  Related Treatments
Bright Light Therapy
Cognitive Behavioral Therapy (CBT)

What is it?

This disorder describes a group of different circadian rhythm sleep disorders (CRSDs) that are directly caused by a drug or substance. People with these disorders have sleep times that seem to be out of alignment. Their sleep patterns do not follow the “normal” sleep times at night.

If the drug or substance problem did not exist, then the CRSD due to drug or substance would not be present. The drug or substance is the identifiable cause of the body clock problem.

The drug can produce any of the abnormal timing patterns seen with these circadian rhythm disorders:

Delayed sleep phase disorder
You fall asleep late (for example, between 4 a.m. and 6 a.m.) every night. As a result you awaken at noon or in the afternoon every day.

Advanced sleep phase disorder
You fall asleep early (for example at 6 p.m.) every night. As a result you awaken early every day (for example at 2 a.m.).

Irregular sleep-wake rhythm
Your sleep pattern is broken up into short pieces. You sleep off and on in a series of naps over a 24-hour period.

Free-running (nonentrained) type
Your sleep time happens later and later every day.

CRSD due to drug or substance is the diagnosis only if there is a specific drug or substance that keeps you from being able to sleep during normal times. If the drug or substance use did not exist, then you would sleep during normal times.

Who gets it?

The rate at which this disorder occurs varies with the type of drug or substance being used. The drug or substance is the direct cause of changes in the timing of sleep. It makes you sleepy at the wrong time or keeps you from sleeping at night. People with weaker body clocks may be more affected by substances than people who have naturally stronger circadian rhythms.

Also, the same medication can produce sleepiness in one person and insomnia in another person. There are too many prescription drugs, over-the counter medications, herbs and vitamins, substances, and illicit drugs to list them all. A few drugs or substances that can cause sleepiness or wakefulness at the wrong time are described below.

Substances that cause sleepiness

These may cause you to unnaturally fall asleep earlier than normal. Then you will wake up earlier than normal. You will appear to have an advanced sleep phase rhythm. If you did not use the drug or substance, then you would not fall asleep early. A few examples of substances that cause sleepiness are:

  • Sleeping pills and other sleeping aids
  • Alcohol
  • Muscle relaxants
    They are frequently sedating and cause sleepiness at the time taken.
  • Pain medications
    They are frequently sedating and cause sleepiness at the time taken.
  • Some antidepressants, anti-anxiety, and antipsychotic medications
    Some cause sleepiness and some cause insomnia. Ask your pharmacist or physician.
  • Parkinson medications
    Some cause sleepiness and some cause insomnia. Ask your pharmacist or physician.
  • Seizure medications may cause sleepiness.
  • Blood pressure, lipid (cholesterol), and heart medications
    Some cause sleepiness and some cause insomnia. Ask your pharmacist or physician.
  • Cancer medications and chemotherapy
    Some cause sleepiness and some cause insomnia. Ask your pharmacist or physician.
  • Antihistamines like “Benadryl®” may cause sleepiness.
  • Allergy, cold, and flu products
    Some cause sleepiness and some cause insomnia. Ask your pharmacist or physician.
  • Herbs, vitamins and minerals, and other substances like tryptophan
    Some cause sleepiness and some cause insomnia. Ask your pharmacist or physician.
  • Melatonin

Some other substances cause wakefulness and insomnia.

These cause you to unnaturally fall asleep later than normal. Then you wake up later than normal. You will appear to have a delayed sleep phase rhythm. A few examples of substances that cause sleepiness are:

  • Caffeine
    A typical cup of coffee has 110 mg of caffeine. A caffeine pill has 50 mg to 200 mg of caffeine. Thus a caffeine pill is similar to one or two cups of coffee. Caffeine is a powerful stimulant. One study showed that six cups of coffee has stimulant effects similar to an amphetamine (5 mg of detroamphetamine).

    Caffeine has a half life of 3 to 5 hours. This means that it is still in your system many hours later. If you have too much caffeine at night, then you may not fall asleep until much later. You will then awaken much later. It will seem like you have delayed sleep phase disorder. You would have otherwise fallen asleep at a normal time if you had not had too much coffee. Or your sleep may be broken into pieces. As a result you may take short daytime naps. Sleeping in pieces at night and during the day may seem like an irregular sleep-wake rhythm.
  • Amphetamines and stimulants
    These substances cause a person to unnaturally stay awake later and then sleep later than normal.
  • Weight control medications
    They may cause wakefulness and insomnia.
  • Steroids
    They can cause wakefulness and insomnia.
  • Some asthma medications
    They can cause wakefulness and insomnia.
  • Parkinson medications
    Some cause sleepiness and some cause insomnia. Ask your pharmacist or physician.
  • Some antidepressants, anti-anxiety, and antipsychotic medications
    Some cause sleepiness and some cause insomnia. Ask your pharmacist or physician.
  • Blood pressure, lipid (cholesterol), and heart medications
    Some cause sleepiness and some cause insomnia. Ask your pharmacist or physician.
  • Cancer medications and chemotherapy
    Some cause sleepiness and some cause insomnia. Ask your pharmacist or physician.
  • Allergy, cold, and flu products
    Some cause sleepiness and some cause insomnia. Ask your pharmacist or physician.
  • Herbs, vitamins and minerals, and other substances like tryptophan
    Some cause sleepiness and some cause insomnia. Ask your pharmacist or physician.

How do I know if I have it?

  1. Do you sleep at the wrong time because of a drug or substance?
  2. Do you sleep at a normal time if you do not take the drug or substance?

If your answer to these questions is yes, then you might have circadian rhythm sleep disorder due to drug or substance.

Do I need to see a sleep specialist?

Yes. You should seek a doctor’s advice. This disorder can cause problems with work and family. You are asleep or are awake at times that are different from family and friends. You would have trouble maintaining relationships and responsibilities.

Having this disorder may make you home bound and isolated. Being home bound can make this condition worse. Because sleep time is out of line with others, some people try behaviors or medicines that might worsen this condition. They may get into trouble if they try to fix this problem on their own by taking more pills or alcohol. Some of these drugs and medications are habit forming. Addiction and tolerance to the substance is possible.

What will the doctor need to know?

The doctor should ask you about your medical, neurologic, and sleep symptoms. The doctor also should ask you about your medications, alcohol, and your family history. Be sure to inform him or her of any past or present drug, alcohol, and medication use. Also tell the doctor if you have ever had any other sleep or neurological disorders.

The doctor should do a thorough medical and neurological exam.

You will be asked to complete a sleep diary to record your natural sleep and wake up times over several weeks. You may be asked to record the timing of any mediations or substances. You may need to take drug tests. You may be asked to rate your sleep with the Epworth Sleepiness Scale.

Will I need to take any tests?

The diagnosis of CRSD due to drug or substance is made clinically and with the use of the sleep diary. You may be asked to wear an actigraph. This is a device that records inactive and active episodes over a period of one to two weeks. An actigraph looks like a funny wrist watch and you wear it day and night.

Other testing methods to measure body temperature or melatonin levels may be used. Most often these methods are used for research.

Your doctor may suspect that a neurological condition or another medical problem is involved. In this case, you may be asked to have blood testing performed. You may also need a CT scan or an MRI.

Some medications and substances can affect your breathing while you sleep. This can increase sleep apnea. They can also increase other sleep disorders such as periodic limb movement disorder. An overnight sleep study is usually not needed to detect a CRSD. You may need to do a sleep study if you are at risk for other sleep disorders. The sleep study is called a polysomnogram. It charts your brain waves, heart beat, muscle activity, and breathing as you sleep. It also records how your arms and legs move. This shows if there are other sleep disorders that are causing or increasing your sleep problems. Examples include sleep apnea and periodic limb movement disorder.

How is it treated?

Treatment for CRSD due to drug or substance is aimed at helping you try to stop taking the drug or substance. When the drug or substance is removed, sleep time should return to normal. For example, the doctor may ask you to cut back on your caffeine intake.

If the medication is required to treat a medical condition, then the doctor may have you try a different medication to treat that condition. For example, changing to a different blood pressure medication may help your sleep and still provide blood pressure treatment. If you have a drug or substance addiction, you will need additional counseling and treatment.

The doctor likely will also recommend good sleep behaviors for you to follow. These will improve your circadian rhythm. Good sleep hygiene is important to keeping one main sleep time. Light, exercise, and other scheduled activities increase stimulation to reset the sleep clock in the brain. Education and behavioral counseling can be helpful. Your progress may be monitored by having you complete sleep logs during treatment.

By Sharon L. Schutte-Rodin, MD
Updated March 27, 2006


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