CLINICAL REVIEWSleep and sleep disorders in adults with attention deficit/hyperactivity disorder
Introduction
In childhood and adolescence, attention deficit/hyperactivity disorder (ADHD) is a common psychiatric disorder characterized by a persistent pattern of impaired attention, impulsive behavior, and hyperactivity. The prevalence rate of ADHD in children ranges from 3–12%, depending on sample selection and diagnostic criteria utilized.1, 2, 3, 4 In 40–60% of the afflicted children, ADHD symptoms persist in adulthood. This includes cases with partial remission.5 The prevalence rate of adults that meet full criteria for ADHD (DSM-IV) is estimated to range from 1% to 2%.5 Formerly, sleep disturbances were included in the ADHD diagnostic criteria for children. However, due to lacking empirical evidence, sleep disturbances were removed from the Third Revised Edition of the Diagnostic and Statistical Manual of Mental Disorders.6 In college students, on the other hand, subjective sleep disorders were found to be predictive for inattention and hyperactivity.7
In clinical practice, adults with ADHD often complain about their sleep disorders. On the other hand, primary sleep disorders can mimic some symptoms of ADHD (attention deficits, concentration problems) and may sometimes be misdiagnosed as ADHD in adults. However, only few studies have investigated sleep quality and sleep disturbances in adults with ADHD. The aim of this review is (1) to summarize the evidence with respect to sleep (assessed either by questionnaires, actigraphy or polysomnography) in adult ADHD, (2) to examine the prevalence of other sleep disorders in adult ADHD and (3) to discuss relevant differential diagnoses that primarily affect the quality of sleep.
We performed a PubMed search for articles published between 1990 and February 2006, limited to adults, using the following key words: attention deficit disorder, attention deficit hyperactivity disorder, inattention, sleep, sleep disorder, and polysomnography.
Section snippets
Prevalence of sleep complaints and sleep EEG changes in adult ADHD
To date, there are no primary epidemiological studies that investigate subjective sleep complaints or large-scale polysomnographic investigations that focus on sleep changes in adult ADHD.
An open-label case-control study was performed by Kooij and coauthors in 2001.8 Her group investigated objective and subjective sleep parameters in eight adult patients with ADHD before and two weeks after pharmacological treatment with either methylphenidate or dextroamphetamine. None of the objective sleep
Spectral power analyses of the sleep EEG in adult ADHD
Lindberg et al. reported increased stage 4 sleep as well as increased delta and theta power from a spectral analysis of the sleep EEG in fourteen homicidal men with antisocial personality disorders and Cloninger type II alcoholism who had suffered from childhood ADHD.15 Interestingly, the absolute and relative amount of stage 4 sleep as well as delta and theta power in this stage were positively correlated with the severity of childhood ADHD, which was retrospectively measured with the Wender
Sleep apnea syndrome
Not only is ADHD a frequent disorder, but so is Obstructive Sleep Apnea Syndrome (OSA). It affects up to 3% of the population17 and is characterized by snoring, frequent nocturnal breathing pauses, curtailed sleep, excessive daytime sleepiness and cognitive deficits.18 Thus, some of the ADHD symptoms, particularly short attention span, may be mimicked by OSA.
To date, three studies have been published investigating the prevalence of OSA in adult ADHD patients.19, 20, 21
In 1998, Scammell et al.19
Discussion
To date, with regard to sleep, the most consistent finding in adult ADHD without sleep disordered breathing is a discrepancy between subjective and objective sleep measurements with essentially normal standard polysomnographic parameters (e.g., sleep latency, wake time, REM and non-REM sleep parameters8, 10). Interestingly, sleep studies in adults with ADHD documented a significantly increased nocturnal motor activity8 and an enhanced frequency of arousals associated with periodic leg movements,
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The most important references are denoted by an asterisk.