A mother arrives with her 17-year-old son and she tells you she is at her wits' end. He is falling asleep in class to the point that he risks failing the year. He has no more school absent or tardy days available. He does not think there is a problem other than an intrusive and annoying mother and home-room teacher. His pediatrician recommended good sleep hygiene and attempted chronotherapy, but he did not make an effort to comply.
His mother cannot wake him in the morning. She enters his room at 6:30 AM and tells him to wake; she screams and shakes him, but he does not budge. She removes his iPad and headphones from the bed and turns on the lights. He will eventually emerge at 10:30 AM having missed his first 2 classes and often sleeps in the third class. Recently he has been staying out until 1 AM, then goes to bed without speaking to her and plays video games under the covers. When he stays at his girlfriend's house on the weekends he wakes about noon and is not sleepy during the day.
You attempt to obtain further history but he rolls his eyes and only grunts one-word answers to your questions. Further questioning about impending failure in school is met with shrugs.
The patient denies illicit drugs or alcohol. He was diagnosed with attention deficit disorder at age 7 and treated with methylphenidate for 3 years. BMI is 26, he denies snoring, and tonsils are present. He used to work out after dinner but has recently lost interest in extracurricular activities. He smokes occasional cigarettes and has 2-3 energy drinks at school for lunch. There is no history of cataplexy or sleep paralysis. Family history is negative for sleep problems.
QUESTION: What is the most likely diagnosis?
insufficient sleep syndrome
irregular sleep wake rhythm disorder
delayed sleep wake phase disorder
motivated delayed sleep-wake phase disorder
ANSWER: e. motivated delayed sleep-wake phase disorder
Although this patient does have delayed sleep phase syndrome (answer d), more specifically, he has the motivated delayed sleep-wake disorder subtype (answer e).1 This condition can be differentiated from generic delayed sleep phase syndrome by the patient's lack of interest in the problem or therapy. He has a history of attention deficit disorder, and the negativity he projects may mask underlying depression—both common conditions in the motivated subtype. Treating the comorbid disorders improves success of circadian realignment.
Answer a is incorrect because he does not have insufficient sleep as he will sleep 8 hours after going to bed. Answer b is incorrect as he does not have the ancillary symptoms of narcolepsy, nor is he excessively sleepy when permitted to sleep later as he does on weekends. Answer c is incorrect since he has a regular sleep and wake time, although it is delayed.
This was not an industry supported study. The authors have indicated no financial conflicts of interest.
Horowitz S. A teenager and his mother. J Clin Sleep Med 2014;10(12):1359-1360.
American Academy of Sleep Medicine. International Classification of Sleep Disorders. 3rd ed. Darien, IL: American Academy of Sleep Medicine, 2014:191–8.