Mechanisms of action for sleep disturbance in neuropsychiatric disorders are multifactorial and poorly understood. The effects of cannabis on sleep, especially the more potent strains currently cultivated, are still unclear. Many substances, including cannabis, suppress rapid-eye-movement (REM) sleep and cause REM-sleep rebound when they are discontinued. Substances with a short half-life, such as tobacco, are especially disruptive of sleep because cravings due to withdrawal are more frequent and intense. Stimulants promote wakefulness by altering neurochemicals, leading to insomnia at night and sleepiness during the day (eg, caffeine blocks adenosine, which prevents the build-up of sleep drive, and amphetamines increase the release of dopamine, which promotes wakefulness). Sedatives such as alcohol, benzodiazepines, and narcotics can shorten sleep onset in the first half of the night but disrupt sleep and cause insomnia due to rebound effects in the second half of the night. The effect of substances on sleep varies depending on the substance. It often results from irregular, inappropriate, or inadequate timing of zeitgebers (“timegivers”) that regulate circadian rhythms, such as exposure to light, engagement in activities, and scheduling of meals and social events. 1 Circadian dysregulation, which reflects changes in the timing of sleep-wake and other behavioral rhythms, occurs in BPD, SSD, ADHD, ASD, and neurodegenerative conditions. Nightmares and associated fear of going to sleep reflect the re-experiencing symptoms and hypervigilance seen in PTSD. Individuals with BPD have reduced sleep need during manic phases and insomnia or hypersomnia during depressive phases. Hypersomnia, which is excessive sleepiness despite a sleep period of 7 hours or more, appears in seasonal affective disorder (SAD) and SSD. Insomnia–problems falling or staying asleep despite adequate opportunity for sleep-occurs in all neuropsychiatric disorders, with sleep-onset problems occurring more frequently in GAD and ASD, and sleep maintenance problems, especially early morning awakenings, more common in MDD. In neuropsychiatric conditions, sleep disturbance most commonly manifests as insomnia, hypersomnia, nightmares, or circadian dysregulation, although some conditions are associated with increased risk for other sleep disorders (eg, sleep apnea in PTSD, restless legs in ADHD). Not surprisingly, disrupted sleep occurs in all substance-use disorders (SUD). 4 It also commonly occurs in schizophrenic spectrum disorders (SSD), autism spectrum disorders (ASD), and neurocognitive disorders due to dementia, cerebrovascular accident, or traumatic brain injury. It disappeared from early editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a criterion for attention-deficit/hyperactivity disorder (ADHD) but has now reappeared in informal guidelines. 2,3 It occurs so frequently in major depressive disorder (MDD), bipolar disorder (BPD), generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD) that it is included in diagnostic criteria. Sleep disturbance is pervasive in almost all neuropsychiatric conditions. Frequency of Sleep Disturbance in Psychiatry Although appropriate medications are essential for effective management of the neuropsychiatric condition, nonpharmacologic approaches such as cognitive-behavioral therapy (CBT) offer highly effective evidence-based treatments for insomnia and adjunctive treatments for hypersomnia, nightmares, and circadian dysregulation. Brief screening instruments help assess for the various types of sleep disturbance common in neuropsychiatric conditions. ![]() Sleep disturbance can be a precipitant or a prodrome, likely through multiple interconnected pathways, and it can also exacerbate symptoms and increase the risk of relapse. 1 It often manifests as insomnia, hypersomnia, nightmares, or circadian dysregulation. Sleep disturbance is so common in neuropsychiatric conditions, it is considered a cross-cutting symptom.
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