AD/HD and SleepBedtime Battles
by William Dodson, M.D.
Many adults don’t know that it is AD/HD that is keeping them up at night—or what’s keeping them from waking up in the morning. Find out how to get the rest you need.
Ah, the thought of getting a good night’s rest, of falling to sleep easily, staying asleep through the night, and then waking up easily—and refreshed. For most people, this bedtime scenario is achievable. But for many with AD/HD, it seems only a dream.
People with AD/HD know how their sleep can be disturbed by their mental and physical restlessness. But, as with most of our knowledge about adults with AD/HD, we’re only beginning to understand a stronger AD/HD-sleep link, resulting in difficulties falling asleep, staying asleep, and waking up.
Sleep disturbances caused by AD/HD have been overlooked for a number of reasons. Sleep problems did not fit neatly into the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) requirement that all AD/HD symptoms must be present by age 7. Sleep disturbances associated with AD/HD generally appear later in life, at around age 12½, on average. Consequently, the arbitrary age cutoff has prevented recognition of sleep disturbances in AD/HD until recently, when studies of adults have become more common. Just as AD/HD does not go away at adolescence, it does not go away at night either. It continues to impair life functioning 24 hours a day.
In early attempts to define the syndrome, sleep disturbances were briefly considered a criterion for AD/HD, but were dropped from the symptoms list because evidence of them was thought to be too nonspecific. As research has expanded to include adults with AD/HD, the causes and effects of sleeping disturbances have become clearer. Many researchers expect them to return as a diagnostic criterion when the criteria for adult AD/HD appear in the DSM V in 2010. For now, sleep problems tend either to be overlooked or to be viewed as coexisting problems with an unclear relationship to AD/HD itself. Sleep disturbances have been incorrectly attributed to the stimulant-class medications that are often the first to be used to treat AD/HD.
THE 4 BIG SLEEP ISSUESNo scientific literature on insomnia lists AD/HD as a prominent cause of sleep disturbances. Most articles focus on sleep disturbance due to stimulant-class medications, rather than looking at AD/HD as the cause. Yet adults with AD/HD know that the connection between their condition and sleep problems is real. Sufferers often call it “perverse sleep”—when they want to be asleep, they are awake; when they want to be awake, they are asleep. The four most common sleep disturbances associated with AD/HD are:
1. Initiation InsomniaAbout three-fourths of all adults with AD/HD report inability to “shut off my mind so I can fall asleep at night.” Many describe themselves as “night owls” who get a burst of energy when the sun goes down. Others report that they feel tired throughout the day, but as soon as the head hits the pillow, the mind clicks on. Their thoughts jump or bounce from one worry to another. Unfortunately, many of these adults describe their thoughts as “racing,” prompting a misdiagnosis of bipolar mood disorder, when this is nothing more than the mental restlessness of AD/HD.
Prior to puberty, 10 to 15 percent of children with AD/HD have trouble getting to sleep. This is twice the rate found in children and adolescents who do not have AD/HD. This number dramatically increases with age: 50 percent of children with AD/HD have difficulty falling asleep almost every night by age 12½; by age 30, more than 70 percent of adults with AD/HD report that they spend more than one hour trying to fall asleep at night.
2. Restless SleepWhen individuals with AD/HD finally fall asleep, their sleep is restless. They toss and turn. They awaken at any noise in the house. They are so fitful that bed partners often choose to sleep in another bed. They often awake to find the bed torn apart and covers kicked onto the floor. Sleep is not refreshing and they awaken as tired as when they went to bed.
3. Difficulty WakingMore than 80 percent of adults with AD/HD in my practice report multiple awakenings until about 4 a.m. Then they fall into “the sleep of the dead,” from which they have extreme difficulty rousing themselves. They sleep through two or three alarms, as well as the attempts of family members to get them out of bed. AD/HD sleepers are commonly irritable, even combative, when roused before they are ready. Many of them say they are not fully alert until noon.
4. Intrusive SleepPaul Wender, M.D., a 30-year veteran AD/HD researcher, relates AD/HD to interest-based performance. As long as persons with AD/HD were interested in or challenged by what they were doing, they did not demonstrate symptoms of the disorder. (This phenomenon is called “hyperfocus” by some, and is often considered to be an AD/HD pattern.) If, on the other hand, an individual with AD/HD loses interest in an activity, his nervous system disengages, in search of something more interesting. Sometimes this disengagement is so abrupt as to induce sudden extreme drowsiness, even to the point of falling asleep. Marian Sigurdson, Ph.D., an expert on electroencephalography (EEG) findings in AD/HD, reports that brain wave tracings at this time show a sudden intrusion of theta waves into the alpha and beta rhythms of alertness. We all have seen “theta wave intrusion,” in the student in the back of the classroom who suddenly crashes to the floor, having “fallen asleep.” This was probably someone with AD/HD who was losing consciousness due to boredom rather than falling asleep. This syndrome is life-threatening if it occurs while driving, and it is often induced by long-distance driving on straight, monotonous roads. Often this condition is misdiagnosed as “EEG negative narcolepsy.” The extent of incidence of intrusive “sleep” is not known, because it occurs only under certain conditions that are hard to reproduce in a laboratory.
WHAT'S GOING ON HERE?There are several theories about the causes of sleep disturbance in people with AD/HD, with a telling range of viewpoints. Physicians base their responses to their patients’ complaints of sleep problems on how they interpret the cause of the disturbances. A physician who looks first for disturbances resulting from disorganized life patterns will treat problems in a different way than a physician who thinks of them as a manifestation of AD/HD.
Thomas Brown, Ph.D., longtime researcher in AD/HD and developer of the Brown Scales, was one of the first to give serious attention to the problem of sleep in children and adolescents with AD/HD. He sees sleep disturbances as indicative of problems of arousal and alertness in AD/HD itself. Two of the five symptom clusters that emerge from the Brown Scales involve activation and arousal:
Organizing and activating to begin work activities.
Sustaining alertness, energy, and effort.
Brown views problems with sleep as a developmentally-based impairment of management functions of the brain—particularly, an impairment of the ability to sustain and regulate arousal and alertness. Interestingly, he does not recommend treatments common to AD/HD, but rather recommends a two-pronged approach that stresses better sleep hygiene and the suppression of unwanted and inconvenient arousal states by using medications with sedative properties.
The simplest explanation is that sleep disturbances are direct manifestations of AD/HD itself. True hyperactivity is extremely rare in women of any age. Most women experience the mental and physical restlessness of AD/HD only when they are trying to shut down the arousal state of day-to-day functioning in order to fall asleep. At least 75 percent of adults of both genders report that their minds restlessly move from one concern to another for several hours until they finally fall asleep. Even then, they toss and turn, awaken frequently, and sometimes barely sleep at all.
The fact that 80 percent of adults with AD/HD eventually fall into “the sleep of the dead” has led researchers to look for explanations. No single theory explains the severe impairment of the ability to rouse oneself into wakefulness. Some AD/HD patients report that they sleep well when they go camping or are out of doors for extended periods of time. Baltimore-based psychiatrist Myron Brenner, M.D., noted the high incidence of AD/HD individuals among the research subjects in his study of Delayed Sleep Phase Syndrome (DSPS). People with DSPS report that they can experience a normal sleep phase—For example, get into bed, fall asleep quickly, sleep undisturbed for eight hours, and awake refreshed—but that their brains and bodies want that cycle from 4 a.m. until noon. This is a pattern reported by more than half of adults with AD/HD. Brenner hypothesizes that DSPS and the sleep patterns of AD/HD have the same underlying disturbance of circadian rhythms. Specifically, he believes that the signal which sets the internal circadian clock (the gradual changes in light caused by the sun’s setting and rising) is weak in people with AD/HD. As a result, their circadian clock is never truly set, and sleep drifts into to the 4 a.m.-to-noon pattern or disappears entirely, until the sufferer is exhausted.
One hypothesis is that the lack of an accurate circadian clock may also account for the difficulty that many with AD/HD have in judging the passage of time. Their internal clocks are not “set.” Consequently, they experience only two times: “now” and “not now.” Many of my adult patients do not wear watches. They experience time as an abstract concept, important to other people, but one which they don’t understand. It will take many more studies to establish the links between circadian rhythms and AD/HD.
HOW TO GET TO SLEEPNo matter how a doctor explains sleep problems, the remedy usually involves something called “sleep hygiene,” which considers all the things that foster the initiation and maintenance of sleep. This set of conditions is highly individualized. Some people need absolute silence. Others need white noise, such as a fan or radio, to mask disturbances to sleep. Some people need a snack before bed, while others can’t eat anything right before bedtime. A few rules of sleep hygiene are universal:
Use the bed only for sleep or sex, not as a place to confront problems or argue.
Have a set bedtime and a bedtime routine and stick to it—rigorously.
Avoid naps during the day.
Two more elements of good sleep hygiene seem obvious, but they should be stressed for people with AD/HD.
Get in bed to go to sleep. Many people with AD/HD are at their best at night. They are most energetic, thinking clearest, and most stable after the sun goes down. The house is quiet and distractions are low. This is their most productive time. Unfortunately, they have jobs and families to which they must attend the next morning, tasks made harder by inadequate sleep.
Avoid caffeine late at night. Although many people without AD/HD report that coffee actually helps them to sleep, there is usually a fine line between the right amount and too much caffeine. Caffeine is a potent diuretic, and while it may help some fall asleep, it causes awakening two or three hours later to void the bladder.
TREATMENT OPTIONSIf the patient spends hours a night with thoughts bouncing and his body tossing, this is probably a manifestation of AD/HD. The best treatment is a does of stimulant-class medication 45 minutes before bedtime. This course of action, however, is a hard sell to patients who suffer from insomnia. Consequently, once they have determined their optimal dose of medication, I ask them to take a nap an hour after they have taken the second dose. Generally, they find that the medication’s “paradoxical effect” of calming restlessness is sufficient to allow them to fall asleep. Most adults are so sleep-deprived that a nap is usually successful. Once people see for themselves, in a “no-risk” situation, that the medications can help them shut off their brains and bodies and fall asleep, they are more willing to try medications at bedtime. About two-thirds of my adult patients take a full dose of their AD/HD medication every night to fall asleep.
What if the reverse clinical history is present? One-fourth of people with AD/HD either don’t have a sleep disturbance or have ordinary difficulty falling asleep. Stimulant-class medications at bedtime are not helpful to them. Dr. Brown recommends Benedryl, 25 to 50 mg, about one hour before bed. Benedryl is an antihistamine sold without prescription and is not habit-forming. The downside is that it is long-acting, and can cause sleepiness for up to 60 hours in some individuals. About 10 percent of those with AD/HD experience severe paradoxical agitation with Benedryl and never try it again.
The next step up the treatment ladder is prescription medications. Most clinicians avoid sleeping pills because they are potentially habit-forming. People quickly develop tolerance to them and require ever-increasing doses. So, the next drugs of choice tend to be non-habit-forming, with significant sedation as a side effect. They are:
Melatonin, a naturally occurring peptide released by the brain in response to the setting of the sun. It has some function in setting the circadian clock. It is available without prescription at most pharmacies and health food stores. Typically the dosage sizes sold are too large. Almost all of the published research on Melatonin is on doses of 1 mg or less, but the doses available on the shelves are either 3 or 6 mg. Nothing is gained by using doses greater than one milligram. Melatonin may not be effective the first night, so several nights’ use may be necessary for effectiveness.
The prescription antihistamine, cyproheptadine (Periactin), which works like Benedryl but has the added advantages of suppressing dreams and reversing stimulant-induced appetite suppression. For those with no appetite loss, weight gain may limit Periactin’s usefulness.
Clonidine, which some practitioners recommend in a 0.05 to 0.1 mg dose one hour before bedtime. This medication is used for high blood pressure, and it is the drug of choice for the hyperactivity component of AD/HD. It exerts significant sedative effects for about four hours.
Antidepressant medications, such as trazadone (Desyrel), 50 to 100 mg, or mirtazapine (Remeron), 15 mg, used by some clinicians for their sedative side effects. Due to a complex mechanism of action, lower doses of mirtazapine are more sedative than higher ones. More is not better. Like Benedryl, these medications tend to produce sedation into the next day, and may make getting up the next morning harder than it was.
PROBLEMS WAKING UPProblems in waking and feeling fully alert can be approached in two ways. The simpler is a two-alarm system. The patient sets a first dose of stimulant-class medication and a glass of water by the bedside. An alarm is set to go off one hour before the person actually plans to rise. When the alarm rings, the patient rouses himself enough to take the medication and goes back to sleep. When a second alarm goes off, an hour later, the medication is approaching peak blood level, giving the individual a fighting chance to get out of bed and start his day.
A second approach is more high-tech, based on evidence that difficulty waking in the morning is a circadian rhythm problem. Anecdotal evidence suggests that the use of sunset/sunrise-simulating lights can set the internal clocks of people with Delayed Sleep Phase Syndrome. As an added benefit, many people report that they sharpen their sense of time and time management once their internal clock is set properly. The lights, however, are experimental and expensive (about $400).
Disturbances of sleep in people with AD/HD are common, but are almost completely ignored by our current diagnostic system and in AD/HD research. These patterns become progressively worse with age. Recognition of sleep disturbance in AD/HD has been hampered by the misattribution of the initial insomnia to the effects of stimulant-class medications. We now recognize that sleep difficulties are associated with AD/HD itself, and that stimulant-class medications are often the best treatment of sleep problems rather than the cause of them.
Dr. William Dodson is a board-certified psychiatrist in Denver, Colorado. He specializes in the treatment of adults with AD/HD. His research interests are in sleep disorders and in the application of theoretical research to everyday practice.
Dos and Don’ts for a Better Night’s Sleep
Do: try a glass of warm milk. Milk contains the amino acid tryptophan- the natural sedative found in turkey- and it could do the trick.
Don’t: drink alcohol before bedtime. The metabolism of alcohol inhibits the ability to stay asleep, and may result in frequent waking. Alcohol is a diuretic, and will also cause awakening to void the bladder.
Do: drink chamomile tea. Chamomile has long been prized for its mild sedative property, which increases when combined with the soothing effect of warm tea.
Don’t: consume anything containing caffeine (including coffee and chocolate) less than four hours before bedtime. In addition to being a stimulant, caffeine is also a potent diuretic, and will cause bathroom trips throughout the night, as will alcohol.
Do: take a hot shower or bath before bed. This will relax muscles and cue the body that it’s time to sleep.
Don’t: eat a large meal too close to bedtime. It takes about four hours to digest a meal, and food in the stomach can be a problem when lying down.
Do: feel free to eat a small snack. When we go for long periods without eating, our bodies send out signals to get more sugar in the bloodstream. This can cause anxiety or physical agitation.
Don’t: take certain medications before bedtime. Surprisingly, many over-the-counter pain medications contain a hefty dose of caffeine. For example, Extra Strength Excedrin contains 130 mg., and Anacin contains 64 mg. An average cup of coffee contains between 65-135 mg. In addition, certain asthma medications, migraine and cold preparations, and antidepressants may contribute to sleeplessness.
Do: get evaluated and/or treated for restless legs syndrome (RLS). The name of this common sleep disorder refers to the “creepy, crawly” sensation in a sufferer’s legs, which causes an urge to move and makes it difficult to get to sleep.
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