Getting enough sleep is important. Without it, we are tired and
lethargic and have problems concentrating. We can have difficulty
handling routine tasks and may be grumpy and irritable. And
that's just after
one night of bad sleep! Imagine the cumulative effect of bad sleep
over a course of weeks, months, or years! A natural treatment
for insomnia and sleep disorders becomes even more important.
Worldwide, one in four people experience difficulty sleeping at some
point, and ten percent of these people claim to have slept poorly most
or every night for a month or more. These sleep difficulties could result
from any of sixty medical causes, varying from psychological
causes, such as depression or anxiety, or physical illnesses such as
restless legs syndrome, periodic leg movements, and conditions that
Light Box Therapy is a Natural Treatment For Sleep
Disorders and Insomnia
For one in four people with sleep difficulties, the cause is a desynchronization
between sleep timing and other daily ("circadian") body rhythms.
Treatment for circadian rhythm sleep disorder is the same as for
Bright light treatment, which consists of daily administration of
artificial bright light of appropriate intensity, duration, and time
of use, has
been shown to be very useful in treating a number of these sleep and
circadian rhythm disorders, specifically: 
Each of these problems will be described in further detail
below, and related treatment with bright light
will be discussed. In the words of one clinical study, "Exposure
to light is the primary synchronizer of the human circadian pacemaker." 
With all of these sleep disorders, treatment may need to occur during
times when bright sunlight is unavailable, so a bright light box purchase
be considered. "Patients are unable to build or buy other lighting
that is as satisfactory as the boxes specifically manufactured to provide
bright light." 
Light Box Therapy for Delayed Sleep Phase Syndrome
(Late to bed, late awakening — night owl syndrome)
Perhaps the most common of the circadian rhythm sleep disorders is
Delayed Sleep Phase Syndrome (DSPS), which occurs mainly in teenagers
adults. It occurs when a person's body clock is running later than
it should, resulting in sleep-onset and wakening times that are very
in relation to the daily cycle of life. It is at the extreme end
of the 'night owl' syndrome: a night owl will typically choose to
midnight, and sleep until 8 in the morning; a person with DSPS is
unable to initiate sleep until well after 1 or 2 am, and has extreme
awakening until late morning or close to noon. [6,7]
During adolescence the biological clock normally shifts to a later
schedule. Most teenagers prefer to have an active evening social life,
staying up until 1 or 2 am, and are sleepy through their morning classes.
For teenagers with DSPS the problem is much worse—they stay up
4 am, and often either arrive very late for school or don't even show
up at all (when they do, they may fall asleep in class).  As a consequence,
their grades suffer, family tensions rise, and life becomes chaotic for
both the teen and those close to him or her.
TREATMENT: Exposure to bright light (10,000 lux for at least 30 minutes
daily or 2,500 lux for at least 2 hours) as soon as possible after awakening
has been found to be extremely helpful in resetting the body clock to
an earlier time.  After some time, which may be days or weeks, depending
on individual response, those employing this method will begin finding
it easier to get up earlier and fall asleep earlier. As this happens,
treatment time should be advanced as well. [10,11]
Once the preferred schedule is achieved the user may cut back to shorter
daily light sessions at the same time each day to maintain this schedule.
Unfortunately, DSPS patients who discontinue use of the bright light
tend to relapse after several days, so maintenance light treatment is
necessary to continue the new sleep pattern. [12,13]
Light Box Therapy for Advanced Sleep Phase Syndrome (ASPS)
(Early to bed, early awakening)
At the opposite end of the spectrum are those affected by Advanced
Sleep Phase Syndrome (ASPS), a condition that primarily affects
 It is characterized by early sleep onset and early morning awakening,
with the inability to maintain sleep past the predawn hours (e.g.,
3-4 am).  As with Delayed Sleep Phase Syndrome [see section
with ASPS typically sleep the same number of hours as those without
sleep phase disorders, they just sleep out of sync with
daily living patterns.
TREATMENT: Again, bright light treatment is highly effective in treating this problem.
Used daily in the evening—about 2 to 4 hours before scheduled bedtime—10,000
lux of light for at least 30 minutes, or 2,500 lux for at least 2 hours,
will gradually delay sleep onset with a subsequent delay of awakening
time. If the bright light treatment is found to be too energizing at
bedtime, it should be scheduled to end at least 1 to 2 hours before the
scheduled bedtime. Once the target schedule is achieved, it can be maintained
by regular use of a shorter duration of bright light in the evening.
Light Box Therapy for Jet Lag
These days, air travel is so convenient and affordable that
almost everyone is familiar with the symptoms of jet lag: sleeplessness
at night and
extreme fatigue during the daytime. These effects occur as a result
of crossing multiple time zones and having one's sleep/wake schedule
of sync with the local time, and is not to be confused with the weariness
of long hours of travel which result from lack of sleep (the latter
can be alleviated simply by catching up on lost sleep). 
Most people crossing more than one time zone in a westward direction
(for example, from New York to Los Angeles), will experience symptoms
similar to those of Advanced Sleep Phase Syndrome [see related section
above]. Eastbound travelers (from the US to Europe, for example) will
experience symptoms similar to those of Delayed Sleep Phase Syndrome
[see related section above]. 
Symptoms of jet lag can be alleviated and quick adaptation to the new
time zone can be achieved by using or avoiding bright light at various
times of day, as outlined below. 
TREATMENT: When attempting to advance the body clock (to an earlier time, as in
eastbound travel) up to 6 time zones, bright light applied in the morning
on the day of departure and perhaps for one or two days beforehand
can significantly reduce the time necessary to adjust to the new
If your travel brings you more than six time zones eastward, it might
be easier to delay your sleep and skip a day (stay awake for 36 hours,
for example, then go to sleep at the appropriate time in the new time
Westbound travel is a lot easier for most people, as it's generally
pretty easy to stay awake for a few extra hours than it is to go to
(when you're not tired), since most people have a natural sleep rhythm
of roughly 25-hours. If you anticipate difficulty staying
awake for the extra
hours, expose yourself to bright light in the evenings upon arrival
and perhaps for a few days before your trip. Avoid bright light in
at your destination until early morning awakening disappears.
Light Box Therapy for Shift Workers
One in five workers in industrialized nations are shift workers. 
In the United States, at least 21 million people work shifts other
the typical 9-to-5 day shift. 40% to 80% of industrial
night shift workers report disturbed sleep, the cardinal symptom
of what has
been described as 'shift maladaptation syndrome'.  Other characteristic
symptoms are fatigue or lack of alertness during waking hours, gastrointestinal
problems, impaired performance, high accident or near-miss rates,
depression and personality changes, and difficult interpersonal relationships.
Averaging 1 to 1½ hours less sleep per 24-hour period than day workers,
both permanent night workers and rotating shift workers on the night
shift experience sleep deprivation caused by a misalignment of the sleep-wake
cycle to biological circadian (daily) rhythms.  Sleep deprivation
and this misalignment of rhythms are two of the most important factors
decreased performance and increased accident rates associated with night
work, and these factors may also impact other health consequences of
shift work, e.g., digestive and cardiovascular. Therefore, changing
to match the imposed sleep-wake schedule may positively impact the overall
health of night workers. 
Because of both social and physiologic pressure to conform to a normal
sleep-wake pattern, night shift workers typically revert to sleeping
at night on their days off, which quickly reverses any partial adaptation
to the night shift they may have attained.  Abruptly attempting to
sleep at normal hours after several nights of working and sleeping during
day is biologically equivalent to a 6- to 10-hour eastbound jet flight,
resulting in disrupted sleep, just as in jet lag.
Studies conducted both in the laboratory—in temporal-isolation
chambers or in laboratories where subjects were confined to the lab,
and in the field—where subjects lived at home and went to work
as usual, have shown
the importance of properly timed exposure to bright light and darkness
in resetting the internal clock which controls
our circadian rhythms. 
In fact, bright light exposure is so powerful a cue for the circadian
pacemaker that it alone can reset the body clock by as much as 12 hours
within only a few days.  The timing, intensity, and duration of the
light exposure is critical for phase-shifting the body clock; given
at the wrong time of day or night, bright light of sufficient intensity
and duration may have no effect on the body clock.  However, properly
timed, it is so successful that NASA, after initiating a bright light
program for both Space Shuttle astronauts and the payload ground crew
who must work nights during missions, has made the program a permanent
part of their Space Shuttle program. 
To precisely determine the timing of bright light application requires
testing in a sleep laboratory by trained sleep specialists, who test
such things as core body temperature and melatonin secretion rhythms.
approach, which is time intensive, may not be practical for most shift
workers to undergo.
TREATMENT: Two approaches have been suggested which would allow people to try bright
light treatment to shift their own rhythms without knowing exactly what
their current rhythms are. In the first method, which has been called
a 'buckshot' approach, it is suggested that long durations (many hours
at one time) of light be administered close to the timing of the daily
temperature minimum, which typically occurs around the midpoint of sleep,
in the hope of hitting the right time to reset the body clock. This approach
could, theoretically, result in great gains in changing circadian rhythms—as
much as a 4-5 hour shift in one night—however, the direction of
that gain may not be the one desired. 
An alternative approach to use, when the direction (either advancing
or delaying rhythms) is important, requires bright light exposure aimed
to one side or the other of the expected temperature minimum, and gradually
moving it on successive days so that it eventually would come
close enough to produce the desired direction of phase shift. If the
to advance circadian rhythms to an earlier time, one would try light
shortly after awakening, and gradually move it earlier each day until
the correct timing is found. If the goal is to delay rhythms, however,
one would use the light before going to sleep, and gradually move it
later each day. 
Another tool for shift workers who wish to improve their sleep is daytime
oral melatonin administration, which lowers core body temperature during
the day and prevents the temperature spike which signals the body and
brain that it's time to wake up. This in turn allows for better daytime
sleep.  However, researchers caution that more studies must be conducted
to determine optimal timing and dosage of oral melatonin, as well as
give sufficient evidence for its effectiveness. 
Comparisons of bright light and melatonin administration for shift workers
show increases in the duration and reported quality of sleep for both
treatments, with bright light having a slight edge over melatonin. Only
bright light, however, is associated with consistently improved performance
levels throughout the night shift, improved sleep quality as measured
by laboratory tests, and greater shifts in circadian rhythms.  Though
melatonin may be helpful in improving sleep for shift workers, at present,
research does not support its use as a primary course of treatment.
While shifting circadian rhythms (and maintaining those shifts) might
be the best approach for permanent night shift workers, a different approach
might be best for rotating shift workers, especially those on rapidly
rotating schedules. Rapidly rotating shift workers might benefit from
a plan that temporarily 'disconnects' their body clock that regulates
sleep and core body temperature. As previously discussed, melatonin 'masks'
the rise in core body temperature that signals the end of sleep, allowing
sleep to be maintained longer than normal. 
Light Box Therapy for Non-24-Hour Sleep-Wake
Syndrome and Dyschronosis
Non-24-Hour Sleep-Wake Syndrome
Almost everyone has a built-in daily
(circadian) rhythm of more than 24 hours, usually between 24.5 and 25.5
hours.  Most people are
naturally able to 'resynchronize' their body clock each day to
the 24-hour light-dark
cycle we call a day, but for a small portion of the population, this
resetting of the body clock does not occur, and non-24-hour sleep-wake
The sleep-wake cycle gradually moves later and later each day, while
the person continues to function in society on a 24-hour schedule. Though
the sleep-wake cycle initially matches the daily rhythm of life, after
a short time, it moves out of sync, and the person has difficulty falling
asleep until well into the night. Gradually, the person is unable to
sleep at all at night, and experiences extreme sleepiness during the
daytime hours. Shortly after that, the person is able to sleep in the
early part of the night, but awakes early in the morning. Eventually,
the sleep-wake cycle again moves back into alignment with the person's
daily rhythm and the person sleeps well for a short time, until the cycle
begins again. 
The majority of reported case of non-24-hour sleep-wake syndrome occur
in blind patients with no conscious perception of light.  Bright
light is the most powerful synchronizer of human circadian rhythms, and
have determined that in some blind people, the pathway that transmits
light signals to the brain remain intact (allowing the daily resetting
of the body clock to occur) despite a complete lack of conscious perception
of light and lack of pupillary response to the bright light of an indirect
TREATMENT: Treatment has proven extremely difficult for this problem. Medication
is of very limited, if any, help.  There is evidence, however, that
bright light treatment administered early in the morning (that
is, shortly after awakening) can have a positive effect on the condition.
 Another helpful approach is to adhere to a strict 24-hour schedule
social time cues (meals, interpersonal interaction, etc.) at specific
times each day to facilitate the resynchronization of the circadian rhythm.
A related problem, dyschronosis, mainly occurs in children
with severe brain injury. These children have a sleep disorder that is
for them and for their families: they sleep in short 'snatches' throughout
the day and night, with a complete lack of sleep consolidation. In one
study, nighttime sleep - the longest period of daily sleep - averaged
only 2.5 hours, with total sleep time for the day of 5 hours, in 15 to
80 minute segments scattered around the clock.
TREATMENT: Medication management
was ineffective; however, five of the fourteen subjects (36%) responded
well to bright light treatment administered daily for 45 minutes each
morning. In fact, after 6 months of treatment, these responders were
sleeping through the night with only one or two short daytime naps. 
Light Box Therapy for Age-Related Insomnia
Complaints of sleeping difficulties increase with age. More than half
of all senior citizens (age 65+) report regular problems with sleep.
 Although the elderly account for 40% of hypnotic medication
(sleeping pill) prescriptions, these medications are of little benefit
age group.  In 1990, a National Institutes of Health Consensus
Development Conference recommended research into more effective
an emphasis on non-pharmacological methods.  Older people often
complain about getting less sleep, of waking frequently at night,
of waking up
too early in the morning, and of being sleepy during the day and
consequently napping. 
Sleep disturbances may be caused by an underlying medical cause such
as sleep apnea or arthritis, or a psychiatric illness such as depression.
Treating the primary illness often leads to resolution of the sleep complaints.
 For many, though, there is no underlying medical problem causing
the sleep disturbance: the problem is a misalignment of the sleep-wake
to other daily cycles of body temperature, melatonin production, etc.,
resulting from a lack of daily exposure to intensities of light sufficient
to anchor daily rhythms. Light exposure among seniors, especially those
living in nursing homes, is much lower than that for younger adults.
In one study, half the subjects spent no time at all in light greater
than 1,000 lux. 
As we age, our circadian clock seems to advance, causing Advanced Sleep
Phase Syndrome [see ASPS section]. One
study reports that older subjects have a shorter daily temperature rhythm
than young subjects—only about 22½ hours, vs. 24½ to 25½ hours for younger people.  In other words, older adults may have
shortened daily rhythms,
which lead necessarily to a significant daily advance in sleep and other
TREATMENT: Bright light exposure in the early evening
or late afternoon often helps lengthen the circadian rhythms of elderly
people with sleep-maintenance
insomnia, and improves both the quality and duration of their sleep.
 The application of bright light is the same as for Advanced Sleep
syndrome [see ASPS section].  When light treatment is withdrawn,
improvement is maintained for a short time. However, after 1-3 months
some subjects again experience early morning awakening, and require bright
light treatment to readjust and to maintain their circadian rhythms.
 Smolensky, M & L Lamberg: The Body Clock Guide to Better Health:
How to Use Your Body's Natural Clock to Fight Illness and Achieve Maximum
Health. New York: Henry Holt & Co., 2000, p 339.
 Terman, M, AJ Lewy, D-J Dijk et al.: Light treatment for sleep disorders:
Consensus report. IV. Sleep phase and duration disturbances. J Biol Rhythms,
10(2): p 136, 1995.
 Duffy, JF, RE Kronauer & CA Czeisler: Phase-shifting human circadian
rhythms: Influence of sleep timing, social contact and light exposure.
J Physiol, 495(1): p 295, 1996.
 Kripke, DF & RT Loving: Bringing therapy to light. Sleep Rev,
 Terman, p 136.
 Smolensky, p 342.
 Terman, p 138.
 Terman, p 138.
 ibid, p 136.
 ibid, p 138.
 Oren, DA, W Reich, NE Rosenthal et al.: How To Beat Jet Lag: A Practical
Guide for Air Travelers. New York: Henry Holt & Co., 1993, pp 2-3.
 Eastman, CI: Light treatment for circadian and sleep disturbances
of shift work. Light Treatment and Biological Rhythms, 6: p 55, 1994.
 Wagner, DR: Disorders of the circadian sleep-wake cycle. Neurologic
Clinics. 14(3): p 664, 1996.
 Eastman, 1994, p 55.
 Wagner, p 665.
 Czeisler, CA, MP Johnson, JF Duffy et al.: Exposure to bright light
and darkness to treat physiologic maladaptation to night work. N E J
Med, 322(18): p 1258, 1990.
 Eastman, CI, Z Boulos, M Terman et al.: Light treatment for sleep
disorders: Consensus report. VI. Shift work. J Biol Rhythms, 10(2): pp
 Wagner, p 665.
 Eastman, 1995(a)
 Czeisler, 1990, p 1254.
 ibid, p 1258.
 Eastman, 1994, p 59.
 Eastman, CI, L Liu & LF Fogg: Circadian rhythm adaptation to
simulated night shift work: effect of nocturnal bright-light duration.
p 405, 1995(b).
 Dawson, D, N Encel & K Lushington: Improving adaptation to simulated
night shift: timed exposure to bright light versus daytime melatonin
administration. Sleep, 18(2): pp 12 & 18, 1995.
 Wagner, p 666.
 Dawson, p 19.
 ibid, p 20.
 Wagner, p 651.
 ibid, p 658.
 Czeisler, CA, TL Shanahan, EB Klerman et al.: Suppression of melatonin
secretion in some blind patients by exposure to bright light. N E J Med,
332: p 8, 1995.
 Wagner, p. 659.
 Czeisler, 1995, p 10.
 Wagner, p 659.
 Guilleminault, C, CC McCann, M Quera-Salva et al.: Light therapy
as treatment of dyschronosis in brain impaired children. Eur J Phediatr,
152: pp 754-759, 1993.
 Ancoli-Israel, S: Sleep problems in older adults: Putting myths
to bed. Geriatrics, 52(1): p 20, 1997.
 Campbell, SS, D Dawson & MW Anderson: Alleviation of sleep maintenance
insomnia with timed exposure to bright light. J Am Ger Soc, 41(8): p
 ibid, p 834.
 Ancoli-Israel, 1997, p 20.
 ibid, p 25.
 Ancoli-Israel, S, DW Jones, L Almendarez et al.: Light exposure
in nursing home patients. Society for Light Treatment and Biological
Abstracts, 4: p 17, 1992.
 Lack, L & H Wright: The effect of evening bright light in delaying
the circadian rhythms and lengthening the sleep of early morning awakening
insomniacs. Sleep, 16(5): p 440, 1993.
 ibid, p 439.
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