Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Case Reports
. 2016 Feb 29:7:17.
doi: 10.3389/fneur.2016.00017. eCollection 2016.

Non-24-Hour Sleep-Wake Disorder Revisited - A Case Study

Affiliations
Case Reports

Non-24-Hour Sleep-Wake Disorder Revisited - A Case Study

Corrado Garbazza et al. Front Neurol. .

Abstract

The human sleep-wake cycle is governed by two major factors: a homeostatic hourglass process (process S), which rises linearly during the day, and a circadian process C, which determines the timing of sleep in a ~24-h rhythm in accordance to the external light-dark (LD) cycle. While both individual processes are fairly well characterized, the exact nature of their interaction remains unclear. The circadian rhythm is generated by the suprachiasmatic nucleus ("master clock") of the anterior hypothalamus, through cell-autonomous feedback loops of DNA transcription and translation. While the phase length (tau) of the cycle is relatively stable and genetically determined, the phase of the clock is reset by external stimuli ("zeitgebers"), the most important being the LD cycle. Misalignments of the internal rhythm with the LD cycle can lead to various somatic complaints and to the development of circadian rhythm sleep disorders (CRSD). Non-24-hour sleep-wake disorders (N24HSWD) is a CRSD affecting up to 50% of totally blind patients and characterized by the inability to maintain a stable entrainment of the typically long circadian rhythm (tau > 24.5 h) to the LD cycle. The disease is rare in sighted individuals and the pathophysiology less well understood. Here, we present the case of a 40-year-old sighted male, who developed a misalignment of the internal clock with the external LD cycle following the treatment for Hodgkin's lymphoma (ABVD regimen, four cycles and AVD regimen, four cycles). A thorough clinical assessment, including actigraphy, melatonin profiles and polysomnography led to the diagnosis of non-24-hour sleep-wake disorders (N24HSWD) with a free-running rhythm of tau = 25.27 h. A therapeutic intervention with bright light therapy (30 min, 10,000 lux) in the morning and melatonin administration (0.5-0.75 mg) in the evening failed to entrain the free-running rhythm, although a longer treatment duration and more intense therapy might have been successful. The sudden onset and close timely connection led us to hypothesize that the chemotherapy might have caused a mutation of the molecular clock components leading to the observed elongation of the circadian period.

Keywords: Hodgkin’s lymphoma; bright light therapy; circadian rhythm sleep disorders; melatonin; non-24-hour sleep-wake disorder.

PubMed Disclaimer

Figures

Figure 1
Figure 1
Actigraphy recording over 5 months (August–December 2012). Note the free-running rhythm of activity (black bars) and sleep-periods (lighter areas) with a calculated intrinsic period of tau = 25.27 h and a mean phase angle of 3.38 ± 2.27 h between dim light melatonin onset (DLMO) and sleep onset. Red spots: DLMO = 3 pg. The patient received 30 min BLT in the morning between October 21, 2012 and December 7, 2012 and oral melatonin in the evening from October 21, 2012 to October 24, 2012 (discontinued due to side effects). During the first days of treatment, sleep onset continued to free-run, while sleep offset remained relatively stable (for ~10 days).
Figure 2
Figure 2
In-lab melatonin suppression test with bright light (BL: 10’000 lux). Schedule: the patient rose at 2:45 a.m. (according to his free-running rhythm), came to our lab at 10 a.m. and was kept under dim light conditions (<8 lux). Saliva samples for melatonin measurement were collected hourly from 11:00 a.m. on. DLMO (3 pg threshold, red dashed line) occurred at 2:16 p.m. The melatonin suppression test was scheduled from 4:30 p.m. to 5:39 p.m. with saliva samples in 15 min intervals. BL (yellow rectangle) caused a significant reduction of melatonin secretion, indicating a normal physiological response via an intact retina–RHT–pineal axis. The patient spent the following night in the lab for PSG recording with sleep onset at 6:40 p.m. and sleep offset at 3:45 a.m.
Figure 3
Figure 3
Range of the intrinsic period length (based on data presented in Ref. (14); n = 157 healthy individuals). The length of the circadian period shows a rather large interindividual variability mimicking a bell distribution centered around 24.15 h (±0.2 h) with extreme taus predisposing to the development of certain circadian rhythm disorders (12). However, the range of normal entrainment, as well as pathological alignment, seems to show rather large overlaps in the length of tau, indicating the influence of other factors in the determination of chronotypes and the development of circadian rhythm sleep disorders, respectively.
Figure 4
Figure 4
Two-factor model of sleep-wake regulation with interactions and genetic modifiers of the involved factors. Sleep regulation is governed by two major factors: the homeostatic process S (A) and the circadian process C (B) (26, 27). However, the exact interaction between these two factors (bold arrows) and individual extend of contribution to the sleep-wake regulation remains unclear. Both processes show considerable interindividual differences: the ability to build up sleep pressure and therefore vulnerability to sleep loss was shown to depend on gene polymorphism of enzymes involved in dopamine and adenosine processing (29, 30) and polymorphisms of the clock gene PER3 (31). The circadian rhythm incorporates two different properties: the bell-distributed, genetically determined cycle length tau and the amplitude of the expressed oscillation [e.g., Bmal1 transcription (33), which influences the vulnerability of the system to resetting stimuli (yellow arrow)]. Potential further interactions between process S and external zeitgebers are indicated as dotted arrows.

Similar articles

Cited by

References

    1. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness Scale. Sleep (1991) 14:50–5. - PubMed
    1. Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res (1989) 28:193–213.10.1016/0165-1781(89)90047-4 - DOI - PubMed
    1. Pagani L, Semenova EA, Moriggi E, Revell VL, Hack LM, Lockley SW, et al. The physiological period length of the human circadian clock in vivo is directly proportional to period in human fibroblasts. PLoS One (2010) 10:e13376.10.1371/journal.pone.0013376 - DOI - PMC - PubMed
    1. Bell-Pedersen D, Cassone VM, Earnest DJ, Golden SS, Hardin PE, Thomas TL, et al. Circadian rhythms from multiple oscillators: lessons from diverse organisms. Nat Rev Genet (2005) 7:544–56.10.1038/nrg1633 - DOI - PMC - PubMed
    1. Albrecht U. Timing to perfection: the biology of central and peripheral circadian clocks. Neuron (2012) 74(2):246–60.10.1016/j.neuron.2012.04.006 - DOI - PubMed

Publication types