Insomnia in adult attention-deficit/hyperactivity disorder: A comparison with borderline personality disorder population in a clinical setting and control participants

A theoretical perspective on the role of sleep in borderline personality disorder: From causative factor to treatment target

Sleep plays a crucial role in emotion regulation. Disturbed sleep is therefore increasingly seen as a potential causal factor for the development and maintenance of affective psychiatric disorders. This may hold especially for borderline personality disorder (BPD), a core emotion dysregulation disorder. Although BPD is strongly associated with sleep disturbances such as insomnia, nightmares and circadian dysrhythmia, research into the role of sleep in BPD remains sparse. In this narrative review, we outline a putative vicious cycle of reciprocal exacerbation of disturbed sleep and emotion dysregulation in BPD, that sheds light on BPD pathophysiology and opens up new avenues for sleep-based treatments. We discuss emotional dysregulation as the base of BPD as well as the observed sleep disturbances in BPD. Based on existing theories of sleep's role in emotion regulation and memory, we then propose several behavioral and neurobiological pathways by which inherent sleep disturbances in BPD may hamper adaptive overnight emotional processing. This likely results in sustained emotional states and associated sleep-disruptive behavior, which in turn negatively impact sleep. We end by proposing a sleep-based research agenda for BPD to further detail the causative role of disturbed sleep in BPD and test the effectiveness of novel sleep-based treatment strategies.

Attention-Deficit/Hyperactivity Disorder and Delayed Sleep Phase Syndrome in Adults: A Randomized Clinical Trial on the Effects of Chronotherapy on Sleep

Delayed sleep phase syndrome (DSPS) is the most common sleep disturbance in adults with attention-deficit/hyperactivity disorder (ADHD). We previously showed that chronotherapy with melatonin effectively advanced the dim-light melatonin onset (DLMO), a biomarker for the internal circadian rhythm, by 1.5 h and reduced ADHD symptoms by 14%. Melatonin combined with bright light therapy (BLT) advanced the DLMO by 2 h, but did not affect ADHD symptoms. This article explores whether sleep times advanced along with DLMO, leading to longer sleep duration and better sleep in general, which might explain the working mechanism behind the reduction in ADHD symptoms after treatment with melatonin. This article presents exploratory secondary analysis on objective and self-reported sleep characteristics from a three-armed double-blind randomized placebo-controlled clinical trial (RCT), which included 49 adults (18-55 years) with ADHD and DSPS. Participants were randomized to receive sleep education and 3 weeks of (1) 0.5 mg/day placebo, (2) 0.5 mg/day melatonin, or (3) 0.5 mg/day melatonin plus 30 min of bright light therapy (BLT) between 0700 and 0800 h. Sleep was assessed at baseline, directly after treatment, and 2 weeks after the end of treatment. Objective measures were obtained by actigraphy, self-reported measures by various sleep questionnaires and a sleep diary. Melatonin with or without BLT did not advance sleep times, improve sleep in general, or strengthen wake-activity rhythms. So even though the DLMO had advanced, sleep timing did not follow. Adding extensive behavioral coaching to chronotherapy is necessary for advancing sleep times along with DLMO and to further alleviate ADHD symptoms.

Attention-Deficit/Hyperactivity Disorder, Insomnia, and Sleepiness Symptoms among a Community Adult Sample: The Mediating Effect of Executive Behavioral Regulation and Metacognition Abilities

OBJECTIVE

Adult attention-deficit/hyperactivity disorder (ADHD) is characterized by a dysexecutive syndrome reflected in cognitive, emotional, and behavioral areas. Independently of a formal diagnosis of ADHD, higher ADHD symptoms are associated with higher levels of insomnia and sleepiness symptoms in adult population-based samples. Insomnia and sleepiness are sleep disorders that are both associated with deficits in several aspects of executive functions which in turn are likely to mimic a range of ADHD symptoms. Our objective was to explore the interrelationships between ADHD, insomnia, and sleepiness symptoms and executive functioning in community-dwelling adults.

METHOD

A total of 442 participants (18-89 years, 56% females) underwent a semistructured clinical interview and completed questionnaires for insomnia, sleepiness, and everyday behaviors in which executive functions are implicated. Mediation Models were applied.

RESULTS

Insomnia and sleepiness symptoms did not play a mediating role between ADHD symptoms and executive functioning. Conversely, our results highlighted a mediating effect of daytime insomnia consequences and sleepiness on ADHD symptoms via behavioral regulation executive symptoms (respectively, β = -0.32, p < .001, 95% CI [-0.46, -0.20]; β = 0.09, p < .05, 95% CI [0.02, 0.16]) and metacognitive executive symptoms (respectively, β = -0.30, p < .001, 95% CI [-0.44, -0.18]; β = 0.12, p < .01, 95% CI [0.04, 0.22]).

CONCLUSIONS

Daytime insomnia consequences and sleepiness symptoms could lead to ADHD-like symptoms through their associated executive symptoms expressed in daily life. When faced with symptoms suggestive of ADHD in adults, insomnia and sleepiness should be systematically screened with standardized instruments.

The impact of insomnia disorder on adult attention-deficit/hyperactivity disorder severity: A six-month follow-up study

BACKGROUND AND OBJECTIVES

The longitudinal relationship between insomnia disorder and adult attention-deficit/hyperactivity disorder (ADHD) has been scarcely investigated. This study aimed to evaluate the relationship between the remission of insomnia disorder and adult ADHD clinical severity, psychiatric and medical comorbidities, and the health-related quality of life (HRQoL) in a 6-month follow-up.

METHODS

Ninety-two adult patients with ADHD and insomnia disorder (52.2% males; mean age 39.5 ± 11.0 years) were comprehensively assessed at baseline, 3 months, and 6 months of a follow-up period. The evaluation included semi-structured interviews (for ADHD and comorbidity assessment), the Pittsburgh Sleep Quality Index, Insomnia Severity Index, and Epworth Sleepiness Scale. The diagnosis of ADHD and insomnia disorder was performed according to DSM-5 criteria. At baseline and follow-up, psychoeducation/sleep hygiene and, if necessary, pharmacological were prescribed for insomnia.

RESULTS

Eighty-seven patients completed the 6-month follow-up. Insomnia disorder remission was reported in 72.4% of cases and was related to a greater improvement in ADHD symptoms and severity throughout the follow-up period. Additionally, an improvement in psychiatric comorbidities and better HRQoL were associated with insomnia disorder remission.

CONCLUSION

The current study highlights that the treatment of insomnia disorder in ADHD adult patients may have an important role in the outcome of ADHD therapeutic approaches by reducing their severity.

Assessment of Insomnia and Associated Factors Among Patients Who Have Recovered from COVID-19 in Vietnam

INTRODUCTION

The COVID-19 pandemic has been affecting the lives of millions of people globally. Patients recovering from COVID-19 are facing, not only the symptom of long COVID, but also psychological problems, such as sleep disturbance. This study aims to assess the proportion of COVID-19 recovered adult patients that suffer from insomnia and associated factors in Vietnam.

METHODS

A cross-sectional study was performed between January and March 2022 among patients who have recovered from a COVID-19 infection. Data were collected based on a self-administered questionnaire that included sociodemographic and standardized questionnaires from the Hospital Anxiety and Depression Scale (HADS), the Perceived stress scale (PSS) and the dependent variable using Insomnia Severity Index (ISI). Multivariable logistic regression was conducted to explore factors associated with the patients' insomnia disorder.

RESULTS

A total of 325 participants were included in this analysis, 34.5% of participants had insomnia. According to multivariable logistic regression, participants who were equal to and over 50 years of age, feeling alienated from others, and were not supported by families or relatives, reported significantly higher levels of insomnia disorders over those aged under 50 years, having closer ties with family and had received support from family or relatives. Besides, respondents who recorded mental health problems that included anxiety, depression and stress were more likely to get insomnia disorders than those without mental health symptoms (OR 2.7, 95% CI 1.1-6.6) (OR 4.5, 95% CI 2.3-8.9) (OR 2.3, 95% CI 1.1-5.3), respectively, all p < 0.05.

CONCLUSION

There was a remarkable rate of COVID-19 recovered patients experiencing insomnia disorders. Older age, alienated relationships and not being supported by families or relatives, as well as had mental health problems, are factors that affected the patients' insomnia, which showed that these sleep issues need to be screened and managed among adults who have recovered from COVID-19.

Profile of subjective-objective sleep discrepancy in patients with insomnia and sleep apnea

STUDY OBJECTIVES

Although subjective-objective sleep discrepancy has long been observed in patients with insomnia, the profiles of this discrepancy are poorly understood. Further, sleep discrepancy in insomnia with sleep comorbidities remains underexplored. We sought to better characterize sleep discrepancy among patient groups with and without insomnia and comorbid conditions such as obstructive sleep apnea (OSA).

METHODS

Using data from the Sleep Heart Health Study, we conducted a secondary analysis describing (1) the profile of self-reported and objective sleep measures in patients with insomnia (IS group; n = 73) and comorbid OSA (IS + OSA group; n = 143), compared with individuals with OSA only (OSA group; n = 296) and normal sleep control patients (NSC group; n = 126); (2) the comparative magnitude of sleep misperception between these 4 groups; and (3) the self-reported quality of life (QOL) in the 4 groups.

RESULTS

Subjective-objective sleep discrepancy existed in all 4 groups, including the NSC group. Controlling for age, sex, mental health conditions, sleep apnea severity, and objectively measured sleep time, the presence of self-reported insomnia had the strongest association with sleep discrepancy. In patients with insomnia, sleep onset latency was overestimated (7.8 ± 36.8 min in the IS group; P < .001 when compared to the NSC and OSA groups), with the largest differences seen in the comorbid IS + OSA group (15.0 ± 56.8 min). Insomnia conferred the most negative impact on QOL, with the combined IS + OSA group reporting the lowest QOL.

CONCLUSIONS

Self-reported insomnia is associated with sleep discrepancy and negative QOL. Those with comorbid OSA reported the greatest sleep discrepancy and the lowest QOL. Future research is warranted to further understand individual profiles of misperception and insomnia phenotypes.

CITATION

Ma Y, Goldstein MR, Davis RB, Yeh GY. Profile of subjective-objective sleep discrepancy in patients with insomnia and sleep apnea. J Clin Sleep Med. 2021;17(11):2155-2163.

Insomnia in Patients with Borderline Personality Disorder

OBJECTIVE

Both sleep disorders and BPD are prevalent in the population, and one is often a comorbidity of the other. This narrative review aims to assess contemporary literature and scientific databases to provide the current state of knowledge about sleep disorders in patients with borderline personality disorder (BPD) and clinical suggestions for managing sleep disorders in BPD patients and future research direction.

METHODS

Articles were acquired via PubMed and Web of Science, and papers published between January 1980 and October 2020 were extracted. Authors made a series of literature searches using the keywords: Sleep problems, Insomnia, Nightmares, Obstructive sleep apnea, Borderline personality disorder. The inclusion criteria were: published in peer-reviewed journals; studies in humans; or reviews on the related topic; English language. The exclusion criteria were: abstracts from conferences; commentaries; subjects younger than 18 years. After an inspection of the full texts, 42 papers from 101 were selected. Secondary documents from the reference lists of the primary designated papers were searched, assessed for suitability, and included. In total, 71 papers were included in the review process.

RESULTS

Sleep disturbance is common among patients with BPD. Nevertheless, the number of investigations is limited, and the prevalence differs between 5-45%. Studies assessing objective changes in sleep architecture in BPD show inconsistent results. Some of them identify REM sleep changes and a decrease in slow-wave sleep, while other studies found no objective sleep architecture changes. There is also a higher prevalence of nightmares in patients with BPD. Untreated insomnia can worsen BPD symptoms via interference with emotional regulation. BPD itself seems to influence the subjective quality of sleep significantly. Proper diagnosis and treatment of sleep disorders in patients with BPD could lead to better results in therapy. Psychotherapeutic approaches can improve both sleep disorders and BPD symptoms.

CONCLUSION

Recognising and managing sleep disorders in patients with BPD may help alleviate the disorder's symptoms. Treatment of people with BPD may be more effective if the treatment plan explicitly addresses sleep problems. Further research is needed to reach reliable conclusions.

Insomnia Disorder in Adult Attention-Deficit/Hyperactivity Disorder Patients: Clinical, Comorbidity, and Treatment Correlates

Introduction: Several investigations have been performed on insomnia symptoms in adult attention-deficit/hyperactivity disorder (ADHD). However, the relationship between insomnia disorder and adult ADHD has been neglected in research. The main objective of the current study is to analyze the differences between adult ADHD patients with and without insomnia disorder, in terms of ADHD clinical severity, medical and psychiatric comorbidity, psychopharmacological treatment, and quality of life. Material and Methods: Two hundred and fifty-two adult patients with ADHD (mean age 37.60 ± 13.22 years; ADHD presentations-combined: 56.7%, inattentive: 39.7%, hyperactive/impulsive: 3.6%) were evaluated with an exhaustive clinical and psychological evaluation protocol including semistructured interviews (for comorbidities and ADHD assessment) and symptom rating scales for ADHD. The diagnosis of ADHD and insomnia disorder was made according to DSM-5 criteria. Furthermore, the Pittsburgh Sleep Quality Index, Insomnia Severity Index, and Epworth Sleepiness Scale were administered. Results: Insomnia disorder was found in 44.4% of adult ADHD patients and was more common in combined presentation (64.3%) and in patients with more ADHD severity. Comorbidities (both medical and psychiatric), especially mood disorders (42%), anxiety disorder (26.8%), personality disorder (39.3%), and any substance use disorder (11.6%), were associated with a higher insomnia disorder prevalence. ADHD stimulant treatment was related to lower insomnia disorder compared to patients without medication, as well as ADHD stable treatment. Additionally, worse health-related quality of life was associated with insomnia disorder. Conclusion: Insomnia disorder is highly prevalent in adult ADHD and is related to higher ADHD severity and more psychiatric and medical comorbidities. Some stimulants and stable pharmacological ADHD treatment are associated with better outcomes of insomnia disorder.

Association of insomnia disorder with sociodemographic factors and poor mental health in COVID-19 inpatients in China

PURPOSE

To examine insomnia disorder and its association with sociodemographic factors and poor mental health in 2019 novel coronavirus (COVID-19) inpatients in Wuhan, China.

DESIGN

and Methods: A total of 484 COVID-19 inpatients in Wuhan Tongji Hospital were selected and interviewed with standardized assessment tools. Insomnia disorder was measured by the Chinese version of the Insomnia Severity Index (ISI-7), a total score of 8 or more was accepted as the threshold for diagnosing insomnia disorder.

RESULTS

The prevalence of insomnia disorder in the whole sample was 42.8%. Binary logistic regression analysis revealed that female gender, younger age, and higher fatigue and anxiety severity were more likely to experience insomnia disorder.

CONCLUSION

Given the high rate of insomnia disorder status among COVID-19 inpatients in Wuhan, China, and its negative effects, follow-up assessments and appropriate psychological interventions for insomnia disorder are needed in this population.

Sleep in adults with autism spectrum disorder and attention deficit/hyperactivity disorder: A systematic review and meta-analysis

Sleep-related problems have been frequently reported in neurodevelopmental disorders, with special emphasis in Autism Spectrum Disorder (ASD) and Attention Deficit/Hyperactivity Disorder (ADHD). The aim of the present study is to conduct a systematic review and meta-analysis on sleep disturbances in adults with ASD and/or ADHD (PROSPERO's CRD42019132916). PubMed and PsycINFO were searched for studies reporting data on sleep objective/subjective measures, as well as prevalence data of sleep disorders, in adults with ASD and/or ADHD. A manual search was conducted throughout reference lists of eligible studies. A total of 1126 studies and 66 references were identified by electronic and manual searches, respectively. Of these, 42 studies were included in the meta-analysis. Results showed that both disorders share a similar sleep-impaired profile with higher sleep onset latency, poorer sleep efficiency, greater number of awakenings during sleep, and a general lower self-perceived sleep quality compared with healthy controls. A higher proportion of N1 sleep was found in ASD participants, while a greater Periodic Limb Movements in Sleep is specific in ADHD adults. More studies are needed, especially those directly comparing ASD and ADHD participants. Controlling for medication, intellectual disability, and concurrent psychiatric disorders is mandatory.

Effects and clinical feasibility of a behavioral treatment for sleep problems in adult attention deficit hyperactivity disorder (ADHD): a pragmatic within-group pilot evaluation

BACKGROUND

Sleep disturbances, including insomnia, are common in adult Attention Deficit Hyperactivity Disorder (ADHD). Treatment of choice for insomnia is cognitive behavioral therapy (CBT-i), but evidence is lacking for CBT-i in patients with ADHD. The purpose of this study was to investigate if patients with insomnia and other sleep problems, at a specialist clinic for ADHD, benefit from a group delivered behavioral treatment based on CBT-i; whether insomnia severity improves following this treatment.

METHODS

This pragmatic within-group pilot study with a pre to post and three-month follow-up design was set at a specialist psychiatric out-patient clinic for adult ADHD. As an adjunct to care-as-usual at the clinic, a CBT-i-based group treatment targeting several sleep problems prevalent in the ADHD-population, was offered as 10 weekly 90-min group sessions and scheduled telephone support. All outcome measures were subjectively reported by participants. Data analyzed with dependent t-tests according to intent-to-treat.

RESULTS

Nineteen patients (37 [SD 13.7] years; 68% female) with ADHD and subjectively reported sleep problems provided informed consent and pre-treatment measures. Patients had suffered from sleep problems for 15.3 [SD 13.4] years, 42% used sleep medications, 79% used stimulant medication(s). At post-treatment, insomnia severity (Insomnia Severity Index; score range 0-28) had improved with 4.5 points (95% CI, 2.06-6.99, p = .002), at 3 months with 6.8 points (95% CI, 4.71-8.91, p < .0001) from pre-treatment.

CONCLUSIONS

CBT-i adjusted for ADHD is promising for improving insomnia severity in adult patients at specialist psychiatric out-patient clinics, who suffer from ADHD and sleep disturbances.

TRIAL REGISTRATION

Study registered with the Regional ethical review board in Stockholm, January 13th 2016, Study id: 2015/2078-31/1. Study registered retrospectively with Clinicaltrials.org, February 21st 2019, ID: NCT03852966.

The impact of depression, anxiety, neuroticism, and severity of Internet addiction symptoms on the relationship between probable ADHD and severity of insomnia among young adults

The aim of the present study was to evaluate the impact of depression, anxiety, neuroticism, and severity of Internet addiction symptoms (IAS) on the relationship between probable attention deficit/hyperactivity disorder (ADHD) and severity of insomnia among young adults. The study was conducted with online survey among 1010 volunteered university students in Ankara, people who are in the e-mail database of a company located in Istanbul that organizes e-sports tournaments and Turkish gamers from gaming forums. Scale scores were higher among the group with high probability of insomnia (n = 200, 19.8%). Also risk of high probability of insomnia was 2.7 times higher among those with probable ADHD. In linear regression analysis, both inattentiveness and hyperactivity/impulsivity dimensions of ADHD were related with the severity of insomnia, together with severities of anxiety, depression, neuroticism and IAS. Similarly, presence of probable ADHD was related with the severity of insomnia in ANCOVA, together with severities of anxiety, depression, neuroticism and IAS. These findings suggest that the presence of probable ADHD and the severity of ADHD symptoms are related with the severity of insomnia, even after controlling the depression, anxiety, neuroticism and IAS, which are all related with the severity of insomnia, among young adults.