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Morning Phototherapy involves exposure to bright light upon awakening. It helps to increase morning alertness and advances the sleep phase in the evening. An inexpensive way to get exposure to bright light (depending on weather conditions, the location and season of the year) is to open the window shades or take a walk in the bright morning sun. Alternatively a specially designed bright light box may be prescribed. These boxes provide between 2,500 and 10,000 lux . Depending on the brightness level, they are used for periods of 30 min to 2 hours. Precise timing of use is critical and is related to the core body temperature minimum. The light is administered about 30 minutes earlier every other day to help gradually advance evening sleep onset. This treatment can be effective in 2 to 3 weeks when combined with evening light avoidance, but often requires ongoing treatment to maintain gains.
Ingestion of oral melatonin later in the day has the effect of advancing the onset of sleep. Proper timing is again critical and is dependent on the dim light melatonin onset which occurs about 14 hours following the habitual wake time. A reasonable estimate for the appropriate time to take melatonin for the purpose of advancing sleep onset is about 8 hours after the natural wake up time. A lower dose is recommended in order to get the clock resetting effect without creating strong drowsiness as may occur with higher doses.
Chronotherapy can be used if there is a flexible enough daytime schedule. Sleep onset is delayed[moved up?] 2 - 3 hours on successive days until the desired bed time is reached.[if desired bed time is -7h, why go +17h?] Obviously, this will be difficult for anyone with a regular work or school schedule. It may be possible to do over a vacation. Once a regular bedtime is established it must be rigorously maintained. Relapse is possible and the process may need to be repeated.
Cognitive behavior therapy is useful to help people improve their sleep hygiene such as keeping a better sleep schedule, decreasing excessive caffeine use and adhering to evening light avoidance. People with delayed sleep phase may also have conditioned arousal that contributes to concomitant insomnia that may be usefully addressed by cognitive behavior therapy.
Delayed sleep phase disorder occurs when there is a delay in the major sleep episode relative to the desired clock time. As a result, the person has a hard time falling asleep and getting up at a normal time. Often people with this problem will use sleeping pills or alcohol to try and get to sleep sooner but this rarely works. Alcohol usually makes the problem worse. It is still unclear to what degree both genetic and environmental factors impact on the development of this disorder but both are most likely involved. People with this disorder may experience depressed mood and have great difficulty functioning at school or work. A delayed sleep phase occurs when people are habitually going to bed later and getting up later than the desired clock time. (An advanced sleep phase, often seen in the elderly, is the opposite. The bed time and rise times occur earlier in the day than is normative.) People with delayed sleep phase disorder typically go to sleep between 2:00 and 6:00 a.m. Delayed sleep phase disorder may last from months to decades, usually starts in adolescence and rarely starts after age 30. A typical goal for treatment would be to have a sleep schedule with a sleep period of 11 p.m. to 7 a.m.
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