A reader asks:

I am 50 years old and have struggled with insomnia for decades. I can even remember not being able to fall asleep as early as five years old. I have always found some way to cope with it even though I would be in a fog most of the time. I have noticed that in the past seven years it is getting out of control and it is constricting my life to the point that I am becoming house bound due to lack of sleep. Sleeping pills don’t touch it; alcohol seems to make it worse. I have tried not sleeping all day for days and to no avail; I end up without any sleep. I have adhered to all the sleep hygiene recommendations, but I can’t seem to fall asleep until 5:00 a.m., or when the sun comes up. Around 7:30 p.m., I take a short nap because I am exhausted, and I am averaging 4 to 5 hours of sleep a day. My room is darkened and I have a very loud fan going to obliterate all other sounds. I think I am going crazy, and no one I know has this problem. If I were to strictly adhere to scheduled use of a bright light, would it give me a sleep schedule that is somewhat normal?


You give lots of information about this difficult situation– not enough to give a definitive answer, but plenty on which to speculate. First, you are not alone with this problem, which is typical of the delayed sleep phase syndrome-in extremis– coupled with a fight to get to sleep on a normal nighttime schedule. As you say, the problem can be life-long, and it can get worse over time. In DSPS, sleeping pills don’t work because they don’t adjust the internal clock earlier, and several common sleep hygiene principles (for example, sleeping at night in a dark room) are irrelevant. One major question is whether, if you allowed yourself to sleep in a dark room during the day, you would have normal sleep duration. That’s an experiment–probably not a solution, assuming you are obligated to function during the day. Light therapy might provide a solution, but it will not work if you simply start doing it in the early morning (which, to you, is really early night).

A general strategy would be to: (a) find out when you awaken in the afternoon after you allow yourself to sleep during the day for several days; (b) begin light therapy at that hour; (c) gradually schedule light therapy (and wake-up) earlier over several weeks; (d) see if you become sleepy and can fall asleep gradually earlier at some point in this process. If it works, you can aim for wake-up when you are now falling asleep, which will need to be maintained by a daily schedule of morning light therapy. It may facilitate the transition to take a low dose of melatonin (1-3 mg) 12 hours before you use the lights–which means gradually, as you move the lights earlier. It may also be worth considering with your doctor the use of a new melatonin-like prescription drug, Rozerem, if you don’t find the melatonin helpful. Finally, keep room lights as low as possible and avoid work, physical activity, caffeine and heavy meals for at least five hours before you sleep. Obviously, you will not be able to keep a normal daytime work schedule during the transition period, so you will need a vacation or leave of absence of up to a month. We make all these suggestions on the assumption that you have DSPS; if the strategy works, you will validate the assumption. It would be best to proceed under monitoring and guidance of a sleep medicine specialist.