Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Delayed sleep-wake phase disorder

R Robert Auger, MD, FAASM, FAPA, DABPN
Section Editors
Cathy A Goldstein, MD
Ronald D Chervin, MD, MS
Deputy Editor
April F Eichler, MD, MPH


Delayed sleep-wake phase disorder (DSWPD) is the most commonly encountered circadian rhythm sleep-wake phase disorder in adolescents. Like other circadian rhythm disorders, DSWPD results from failure to synchronize internal circadian rhythms to the environmental light/dark cycle.

Individuals with DSWPD have a pronounced "night owl" circadian preference. Affected individuals habitually go to bed and wake up significantly later than conventional or desired times. Unlike unaffected "night owls," patients with DSWPD cannot conform to a sleep schedule that is compatible with personal, professional, or academic obligations.

This topic reviews the clinical features, diagnosis, and management of DSWPD. Behavioral sleep problems and other sleep disorders in children are reviewed separately. (See "Behavioral sleep problems in children" and "Assessment of sleep disorders in children".)


The prevalence of delayed sleep-wake phase disorder (DSWPD) is not well established, and estimates range widely. Studies using questionnaires, telephone surveys, or mixed subjective and objective measures have identified DSWPD in 0.1 to 3 percent of the general population [1-4].

Studies consistently show a peak prevalence in adolescence, although point estimates in this age group vary by country of origin [2,4-7]. For example, studies of American and Norwegian adolescents have reported a prevalence as high as 7 to 8 percent [7,8], whereas one study involving Japanese young people estimated a prevalence <1 percent, peaking at 1.7 percent among four-year university students [6]. A systematic study involving over 1000 Western European adolescents, aged 15 to 18 years, reported a similarly low rate of circadian disorders of any type (<1 percent) [9]. Differences in school start times (later in Western Europe compared with many high schools in the United States) may explain some of the regional variability.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Dec 2016. | This topic last updated: Mon Feb 08 00:00:00 GMT 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Schrader H, Bovim G, Sand T. The prevalence of delayed and advanced sleep phase syndromes. J Sleep Res 1993; 2:51.
  2. Yazaki M, Shirakawa S, Okawa M, Takahashi K. Demography of sleep disturbances associated with circadian rhythm disorders in Japan. Psychiatry Clin Neurosci 1999; 53:267.
  3. Wyatt JK. Delayed sleep phase syndrome: pathophysiology and treatment options. Sleep 2004; 27:1195.
  4. Ando K, Kripke DF, Ancoli-Israel S. Estimated prevalence of delayed and advanced sleep phase syndromes. J Sleep Res 1995; 24:509.
  5. Pelayo R, Thorpy M, Govinski P. Prevalence of delayed sleep phase disorder among adolescents. Sleep Res 1988; 17:392.
  6. Hazama GI, Inoue Y, Kojima K, et al. The prevalence of probable delayed-sleep-phase syndrome in students from junior high school to university in Tottori, Japan. Tohoku J Exp Med 2008; 216:95.
  7. Saxvig IW, Pallesen S, Wilhelmsen-Langeland A, et al. Prevalence and correlates of delayed sleep phase in high school students. Sleep Med 2012; 13:193.
  8. Sivertsen B, Pallesen S, Stormark KM, et al. Delayed sleep phase syndrome in adolescents: prevalence and correlates in a large population based study. BMC Public Health 2013; 13:1163.
  9. Ohayon MM, Roberts RE, Zulley J, et al. Prevalence and patterns of problematic sleep among older adolescents. J Am Acad Child Adolesc Psychiatry 2000; 39:1549.
  10. Ancoli-Israel S, Schnierow B, Kelsoe J, Fink R. A pedigree of one family with delayed sleep phase syndrome. Chronobiol Int 2001; 18:831.
  11. Sack RL, Auckley D, Auger RR, et al. Circadian rhythm sleep disorders: part II, advanced sleep phase disorder, delayed sleep phase disorder, free-running disorder, and irregular sleep-wake rhythm. An American Academy of Sleep Medicine review. Sleep 2007; 30:1484.
  12. Carskadon MA, Acebo C. Regulation of sleepiness in adolescents: update, insights, and speculation. Sleep 2002; 25:606.
  13. Andrade MM, Benedito-Silva AA, Domenice S, et al. Sleep characteristics of adolescents: a longitudinal study. J Adolesc Health 1993; 14:401.
  14. National Sleep Foundation. Adolescent Sleep Needs and Patterns: Research Report and Resource Guide, National Sleep Foundation, Washington, DC 2012.
  15. National Sleep Foundation. 2006 Sleep in America Poll: Summary of Findings. Available at: https://sleepfoundation.org/sites/default/files/2006_summary_of_findings.pdf (Accessed on July 03, 2008).
  16. Laberge L, Petit D, Simard C, et al. Development of sleep patterns in early adolescence. J Sleep Res 2001; 10:59.
  17. Giannotti F, Cortesi F, Sebastiani T, Ottaviano S. Circadian preference, sleep and daytime behaviour in adolescence. J Sleep Res 2002; 11:191.
  18. Gau SF, Soong WT. The transition of sleep-wake patterns in early adolescence. Sleep 2003; 26:449.
  19. Ouyang F, Lu BS, Wang B, et al. Sleep patterns among rural Chinese twin adolescents. Sleep Med 2009; 10:479.
  20. Sadeh A, Dahl RE, Shahar G, Rosenblat-Stein S. Sleep and the transition to adolescence: a longitudinal study. Sleep 2009; 32:1602.
  21. Carskadon MA, Wolfson AR, Acebo C, et al. Adolescent sleep patterns, circadian timing, and sleepiness at a transition to early school days. Sleep 1998; 21:871.
  22. Crowley SJ, Acebo C, Carskadon MA. Sleep, circadian rhythms, and delayed phase in adolescence. Sleep Med 2007; 8:602.
  23. Roenneberg T, Kuehnle T, Pramstaller PP, et al. A marker for the end of adolescence. Curr Biol 2004; 14:R1038.
  24. American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014.
  25. Dagan Y, Stein D, Steinbock M, et al. Frequency of delayed sleep phase syndrome among hospitalized adolescent psychiatric patients. J Psychosom Res 1998; 45:15.
  26. Thorpy MJ, Korman E, Spielman AJ, Glovinsky PB. Delayed sleep phase syndrome in adolescents. J Adolesc Health Care 1988; 9:22.
  27. Carskadon MA, Vieira C, Acebo C. Association between puberty and delayed phase preference. Sleep 1993; 16:258.
  28. Carskadon MA, Acebo C, Richardson GS, et al. An approach to studying circadian rhythms of adolescent humans. J Biol Rhythms 1997; 12:278.
  29. Jenni OG, Achermann P, Carskadon MA. Homeostatic sleep regulation in adolescents. Sleep 2005; 28:1446.
  30. Weitzman ED, Czeisler CA, Coleman RM, et al. Delayed sleep phase syndrome. A chronobiological disorder with sleep-onset insomnia. Arch Gen Psychiatry 1981; 38:737.
  31. Carskadon MA, Acebo C. Intrinsic circadian period in adolescents versus adults from forced desynchrony. Sleep 2005; 28:A71.
  32. Hummer DL, Jechura TJ, Mahoney MM, Lee TM. Gonadal hormone effects on entrained and free-running circadian activity rhythms in the developing diurnal rodent Octodon degus. Am J Physiol Regul Integr Comp Physiol 2007; 292:R586.
  33. McGinnis MY, Lumia AR, Tetel MJ, et al. Effects of anabolic androgenic steroids on the development and expression of running wheel activity and circadian rhythms in male rats. Physiol Behav 2007; 92:1010.
  34. Micic G, de Bruyn A, Lovato N, et al. The endogenous circadian temperature period length (tau) in delayed sleep phase disorder compared to good sleepers. J Sleep Res 2013; 22:617.
  35. Aoki H, Ozeki Y, Yamada N. Hypersensitivity of melatonin suppression in response to light in patients with delayed sleep phase syndrome. Chronobiol Int 2001; 18:263.
  36. Auger RR, Burgess HJ, Dierkhising RA, et al. Light exposure among adolescents with delayed sleep phase disorder: a prospective cohort study. Chronobiol Int 2011; 28:911.
  37. Hagenauer MH, Perryman JI, Lee TM, Carskadon MA. Adolescent changes in the homeostatic and circadian regulation of sleep. Dev Neurosci 2009; 31:276.
  38. Crowley SJ, Carskadon MA. Modifications to weekend recovery sleep delay circadian phase in older adolescents. Chronobiol Int 2010; 27:1469.
  39. Sharkey KM, Carskadon MA, Figueiro MG, et al. Effects of an advanced sleep schedule and morning short wavelength light exposure on circadian phase in young adults with late sleep schedules. Sleep Med 2011; 12:685.
  40. Figueiro MG, Rea MS. Lack of short-wavelength light during the school day delays dim light melatonin onset (DLMO) in middle school students. Neuro Endocrinol Lett 2010; 31:92.
  41. Harada T, Morisane H, Takeuchi H. Effect of daytime light conditions on sleep habits and morningness-eveningness preference of Japanese students aged 12-15 years. Psychiatry Clin Neurosci 2002; 56:225.
  42. Burkhart K, Phelps JR. Amber lenses to block blue light and improve sleep: a randomized trial. Chronobiol Int 2009; 26:1602.
  43. Brainard GC, Hanifin JP, Greeson JM, et al. Action spectrum for melatonin regulation in humans: evidence for a novel circadian photoreceptor. J Neurosci 2001; 21:6405.
  44. Patten SB, Lauderdale WM. Delayed sleep phase disorder after traumatic brain injury. J Am Acad Child Adolesc Psychiatry 1992; 31:100.
  45. Nagtegaal JE, Kerkhof GA, Smits MG, et al. Traumatic brain injury-associated delayed sleep phase syndrome. Funct Neurol 1997; 12:345.
  46. Quinto C, Gellido C, Chokroverty S, Masdeu J. Posttraumatic delayed sleep phase syndrome. Neurology 2000; 54:250.
  47. Ayalon L, Borodkin K, Dishon L, et al. Circadian rhythm sleep disorders following mild traumatic brain injury. Neurology 2007; 68:1136.
  48. Wirz-Justice A, Haug HJ, Cajochen C. Disturbed circadian rest-activity cycles in schizophrenia patients: an effect of drugs? Schizophr Bull 2001; 27:497.
  49. Hermesh H, Lemberg H, Abadi J, Dagan Y. Circadian rhythm sleep disorders as a possible side effect of fluvoxamine. CNS Spectr 2001; 6:511.
  50. Mercer PW, Merritt SL, Cowell JM. Differences in reported sleep need among adolescents. J Adolesc Health 1998; 23:259.
  51. Wolfson AR, Carskadon MA. Sleep schedules and daytime functioning in adolescents. Child Dev 1998; 69:875.
  52. Eaton DK, McKnight-Eily LR, Lowry R, et al. Prevalence of insufficient, borderline, and optimal hours of sleep among high school students - United States, 2007. J Adolesc Health 2010; 46:399.
  53. Alvarez B, Dahlitz MJ, Vignau J, Parkes JD. The delayed sleep phase syndrome: clinical and investigative findings in 14 subjects. J Neurol Neurosurg Psychiatry 1992; 55:665.
  54. Ohta T, Iwata T, Kayukawa Y, Okada T. Daily activity and persistent sleep-wake schedule disorders. Prog Neuropsychopharmacol Biol Psychiatry 1992; 16:529.
  55. Nagtegaal JE, Laurant MW, Kerkhof GA, et al. Effects of melatonin on the quality of life in patients with delayed sleep phase syndrome. J Psychosom Res 2000; 48:45.
  56. Fernandez-Mendoza J, Iliuodi C, Montes MI, et al. Circadian preference, nighttime sleep and daytime functioning in young adulthood. Sleep Biol Rhythms 2010; 8:52.
  57. Campbell SS, Murphy PJ. Delayed sleep phase disorder in temporal isolation. Sleep 2007; 30:1225.
  58. Regestein QR, Pavlova M. Treatment of delayed sleep phase syndrome. Gen Hosp Psychiatry 1995; 17:335.
  59. Takahashi Y, Hohjoh H, Matsuura K. Predisposing factors in delayed sleep phase syndrome. Psychiatry Clin Neurosci 2000; 54:356.
  60. Shirayama M, Shirayama Y, Iida H, et al. The psychological aspects of patients with delayed sleep phase syndrome (DSPS). Sleep Med 2003; 4:427.
  61. Kripke DF, Rex KM, Ancoli-Israel S, et al. Delayed sleep phase cases and controls. J Circadian Rhythms 2008; 6:6.
  62. Abe T, Inoue Y, Komada Y, et al. Relation between morningness-eveningness score and depressive symptoms among patients with delayed sleep phase syndrome. Sleep Med 2011; 12:680.
  63. Lee HJ, Rex KM, Nievergelt CM, et al. Delayed sleep phase syndrome is related to seasonal affective disorder. J Affect Disord 2011; 133:573.
  64. Rahman SA, Kayumov L, Shapiro CM. Antidepressant action of melatonin in the treatment of Delayed Sleep Phase Syndrome. Sleep Med 2010; 11:131.
  65. Kitamura S, Hida A, Watanabe M, et al. Evening preference is related to the incidence of depressive states independent of sleep-wake conditions. Chronobiol Int 2010; 27:1797.
  66. Okawa M, Uchiyama M. Circadian rhythm sleep disorders: characteristics and entrainment pathology in delayed sleep phase and non-24-h sleep-wake syndrome. Sleep Med Rev 2007; 11:485.
  67. Ahn YM, Chang J, Joo YH, et al. Chronotype distribution in bipolar I disorder and schizophrenia in a Korean sample. Bipolar Disord 2008; 10:271.
  68. Staton D. The impairment of pediatric bipolar sleep: hypotheses regarding a core defect and phenotype-specific sleep disturbances. J Affect Disord 2008; 108:199.
  69. Faedda GL, Teicher MH. Objective measures of activity and attention in the differential diagnosis of psychiatric disorders of childhood. Essent Psychopharmacol 2005; 6:239.
  70. Turner J, Drummond LM, Mukhopadhyay S, et al. A prospective study of delayed sleep phase syndrome in patients with severe resistant obsessive-compulsive disorder. World Psychiatry 2007; 6:108.
  71. Mukhopadhyay S, Fineberg NA, Drummond LM, et al. Delayed sleep phase in severe obsessive-compulsive disorder: a systematic case-report survey. CNS Spectr 2008; 13:406.
  72. Monteleone P, Catapano F, Del Buono G, Maj M. Circadian rhythms of melatonin, cortisol and prolactin in patients with obsessive-compulsive disorder. Acta Psychiatr Scand 1994; 89:411.
  73. Millet B, Touitou Y, Poirier MF, et al. Plasma melatonin and cortisol in patients with obsessive-compulsive disorder: relationship with axillary temperature, physical activity, and clinical symptoms. Biol Psychiatry 1998; 44:874.
  74. Van der Heijden KB, Smits MG, Van Someren EJ, et al. Effect of melatonin on sleep, behavior, and cognition in ADHD and chronic sleep-onset insomnia. J Am Acad Child Adolesc Psychiatry 2007; 46:233.
  75. Dahl RE, Pelham WE, Wierson M. The role of sleep disturbances in attention deficit disorder symptoms: a case study. J Pediatr Psychol 1991; 16:229.
  76. Kotagal S, Broomall E. Sleep in children with autism spectrum disorder. Pediatr Neurol 2012; 47:242.
  77. Morgenthaler T, Alessi C, Friedman L, et al. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Sleep 2007; 30:519.
  78. Horne JA, Ostberg O. A self-assessment questionnaire to determine morningness-eveningness in human circadian rhythms. Int J Chronobiol 1976; 4:97.
  79. Sack RL, Auckley D, Auger RR, et al. Circadian rhythm sleep disorders: part I, basic principles, shift work and jet lag disorders. An American Academy of Sleep Medicine review. Sleep 2007; 30:1460.
  80. Shibui K, Uchiyama M, Okawa M. Melatonin rhythms in delayed sleep phase syndrome. J Biol Rhythms 1999; 14:72.
  81. Ozaki S, Uchiyama M, Shirakawa S, Okawa M. Prolonged interval from body temperature nadir to sleep offset in patients with delayed sleep phase syndrome. Sleep 1996; 19:36.
  82. Shibui K, Uchiyama M, Kim K, et al. Melatonin, cortisol and thyroid-stimulating hormone rhythms are delayed in patients with delayed sleep phase syndrome. Sleep Biol Rhythms 2003; 1:209.
  83. Campbell SS, Dawson D, Anderson MW. Alleviation of sleep maintenance insomnia with timed exposure to bright light. J Am Geriatr Soc 1993; 41:829.
  84. Lack L, Wright H. The effect of evening bright light in delaying the circadian rhythms and lengthening the sleep of early morning awakening insomniacs. Sleep 1993; 16:436.
  85. Lack L, Wright H, Kemp K, Gibbon S. The treatment of early-morning awakening insomnia with 2 evenings of bright light. Sleep 2005; 28:616.
  86. Burgess HJ, Eastman CI. A late wake time phase delays the human dim light melatonin rhythm. Neurosci Lett 2006; 395:191.
  87. Taylor A, Wright HR, Lack LC. Sleeping-in on the weekend delays circadian phase and increases sleepiness the following week. Sleep Biol Rhythms 2008; 6:172.
  88. Eastman CI, Gazda CJ, Burgess HJ, et al. Advancing circadian rhythms before eastward flight: a strategy to prevent or reduce jet lag. Sleep 2005; 28:33.
  89. Auger RR, Burgess HJ, Emens JS, et al. Clinical Practice Guideline for the Treatment of Intrinsic Circadian Rhythm Sleep-Wake Disorders: Advanced Sleep-Wake Phase Disorder (ASWPD), Delayed Sleep-Wake Phase Disorder (DSWPD), Non-24-Hour Sleep-Wake Rhythm Disorder (N24SWD), and Irregular Sleep-Wake Rhythm Disorder (ISWRD). An Update for 2015: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med 2015; 11:1199.
  90. Wahistrom K. Changing times: Findings from the first longitudinal study of later high school start times. NASSP Bulletin 2002; 86:3.
  91. Owens JA, Belon K, Moss P. Impact of delaying school start time on adolescent sleep, mood, and behavior. Arch Pediatr Adolesc Med 2010; 164:608.
  92. Adolescent Sleep Working Group, Committee on Adolescence, Council on School Health. School start times for adolescents. Pediatrics 2014; 134:642.
  93. Thacher PV, Onyper SV. Longitudinal Outcomes of Start Time Delay on Sleep, Behavior, and Achievement in High School. Sleep 2016; 39:271.
  94. Danner F, Phillips B. Adolescent sleep, school start times, and teen motor vehicle crashes. J Clin Sleep Med 2008; 4:533.
  95. Morgenthaler T, Kramer M, Alessi C, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An american academy of sleep medicine report. Sleep 2006; 29:1415.
  96. van Geijlswijk IM, van der Heijden KB, Egberts AC, et al. Dose finding of melatonin for chronic idiopathic childhood sleep onset insomnia: an RCT. Psychopharmacology (Berl) 2010; 212:379.
  97. Smits MG, Nagtegaal EE, van der Heijden J, et al. Melatonin for chronic sleep onset insomnia in children: a randomized placebo-controlled trial. J Child Neurol 2001; 16:86.
  98. Mundey K, Benloucif S, Harsanyi K, et al. Phase-dependent treatment of delayed sleep phase syndrome with melatonin. Sleep 2005; 28:1271.
  99. Buscemi N, Vandermeer B, Hooton N, et al. The efficacy and safety of exogenous melatonin for primary sleep disorders. A meta-analysis. J Gen Intern Med 2005; 20:1151.
  100. Ferracioli-Oda E, Qawasmi A, Bloch MH. Meta-analysis: melatonin for the treatment of primary sleep disorders. PLoS One 2013; 8:e63773.
  101. Herxheimer A, Petrie KJ. Melatonin for the prevention and treatment of jet lag. Cochrane Database Syst Rev 2002; :CD001520.
  102. Committee on the Framework for Evaluating the Safety of the Dietary Supplements, Food and Nutrition Board, Board on Life Sciences, Institute of Medicine and National Research Council of the National Academies. Dietary Supplements: A Framework for Evaluating Safety, The National Academies Press, Washington 2005.
  103. Werneke U, Turner T, Priebe S. Complementary medicines in psychiatry: review of effectiveness and safety. Br J Psychiatry 2006; 188:109.
  104. Spadoni G, Bedini A, Rivara S, Mor M. Melatonin receptor agonists: new options for insomnia and depression treatment. CNS Neurosci Ther 2011; 17:733.
  105. National Research Council. Melatonin: Prototype monograph summary. In: Dietary Supplements: A Framework for Evaluating Safety, The National Academies Press, Washington, DC 2005.
  106. Seabra ML, Bignotto M, Pinto LR Jr, Tufik S. Randomized, double-blind clinical trial, controlled with placebo, of the toxicology of chronic melatonin treatment. J Pineal Res 2000; 29:193.
  107. Valcavi R, Zini M, Maestroni GJ, et al. Melatonin stimulates growth hormone secretion through patheways other than the growth hormone-releasing hormone. Clin Endocrinol (Oxf) 1993; 39:193.
  108. Luboshitzky R, Shen-Orr Z, Nave R, et al. Melatonin administration alters semen quality in healthy men. J Androl 2002; 23:572.
  109. Hoebert M, van der Heijden KB, van Geijlswijk IM, Smits MG. Long-term follow-up of melatonin treatment in children with ADHD and chronic sleep onset insomnia. J Pineal Res 2009; 47:1.
  110. Wasdell MB, Jan JE, Bomben MM, et al. A randomized, placebo-controlled trial of controlled release melatonin treatment of delayed sleep phase syndrome and impaired sleep maintenance in children with neurodevelopmental disabilities. J Pineal Res 2008; 44:57.
  111. Carr R, Wasdell MB, Hamilton D, et al. Long-term effectiveness outcome of melatonin therapy in children with treatment-resistant circadian rhythm sleep disorders. J Pineal Res 2007; 43:351.
  112. van Geijlswijk IM, Mol RH, Egberts TC, Smits MG. Evaluation of sleep, puberty and mental health in children with long-term melatonin treatment for chronic idiopathic childhood sleep onset insomnia. Psychopharmacology (Berl) 2011; 216:111.
  113. Gradisar M, Dohnt H, Gardner G, et al. A randomized controlled trial of cognitive-behavior therapy plus bright light therapy for adolescent delayed sleep phase disorder. Sleep 2011; 34:1671.
  114. Cole RJ, Smith JS, Alcalá YC, et al. Bright-light mask treatment of delayed sleep phase syndrome. J Biol Rhythms 2002; 17:89.
  115. Terman M. Circadian rhythm phase advance with dawn simulation treatment for winter depression. J Biol Rhythms 2010; 25:297.
  116. Ito A, Ando K, Hayakawa T, et al. Long-term course of adult patients with delayed sleep phase syndrome. Jpn J Psychiatry Neurol 1993; 47:563.
  117. Mizuma H, Miyahara Y, Sakamoto T, et al. Two cases of delayed sleep phase syndrome (DSPS). Jpn J Psychiatry Neurol 1991; 45:163.
  118. Yamadera H, Takahashi K, Okawa M. A multicenter study of sleep-wake rhythm disorders: clinical features of sleep-wake rhythm disorders. Psychiatry Clin Neurosci 1996; 50:195.