I’m going to describe three common sleep problems that go along with ADHD, and what to do about them.

ADHD.

Attention Deficit.

Hyperactivity.

Disorder.

I broke the words up for ya! In case you have ADHD or something. I’m a popular expert on the topic thanks to a loud mouth, it seems…

ADHD is not called Attention Allocation Disorder. Variable attention is normal. It’s problematic when the attention gas tank runs low… giving you too little attention for the task at hand.

ADHD is “a disorder” in the same way that your car running out of gas is “a disorder.” It’s not a problem with the car. It’s a problem for going somewhere. There are car use cases, like clumsily kissing in a Jeep Grand Cherokee in the Taft High School Parking lot in 1996, in which the gas in tank isn’t a factor.

Sleep: It’s Important

The amount of attention you have available to you matters. Sleep fills up the gas tank.

ADHD, on the other hand, can make it hard to sleep.

The quality of the sleep, you have—and this is a factor of the what is happening in your brain when you’re sleeping—determines how much your attention gas tank and gets filled up by the sleep you get.

The next sentence is better if you imagine a 1950s radio advertisement announcer reading it:

“With Sleep, you can have more attention available.”

1. Stimulant Treatment Leading to Problems Falling Asleep

The attention promoting effects of stimulants and the wakefulness promoting effects have different timelines. Sleep is actually pretty complicated biology, so here is a link to a video that makes it really clear.

It may be surprising, but ADHD stimulant treatment is related to lower insomnia disorder rates compared to patients without medication in one study.

If you take a high dose of a stimulant, and it lasts in your system too long, you don’t fall asleep on time. And then you have trouble paying attention. And then you need a higher dose of stimulant. Repeat.

This is the same problem as trying to run a humidifier and a dehumidifier in a room at the same time. It’s unwise.

My Opinion:

Work with your doctor to find the appropriate dosing schedule that allows you to fall asleep at night. Long acting stimulants are commonly prescribed. Some individuals break down Amphetamine Salts slowly—because of variability in metabolism. For nerds: this happens at cytochrome P450 liver enzymes like 3a4/3a51. This can mean long acting stimulants can last too long for your ideal bedtime.

2. Obstructive Sleep Apnea (OSA)

Share The Frontier Psychiatrists

Obstructive sleep apnea is common in ADHD. It occurs when the resting muscle tone that we maintain during the day relaxes… when we fall asleep. This can lead to the airway closing off. This is especially common in people who are overweight or obese. If your neck is big, it weighs more, and gravity will pull it downward at night. And they said physics on the MCAT doesn’t matter! (Thanks, colleagues at Mayo Clinic for the video!)

When your airway closes off, this causes a brief period of not breathing, referred to as “apnea”

Pnea= breath

A= not

A-pnea = not breathing

The obstructive word means that something is physically in the way of the breathing. This is different problem than if your brain forgot to breathe which is called central apnea.

The body’s solution to not breathing in your sleep is to briefly wake up. This restores muscle tone that keeps your airway open, and you can breathe again. But you stop sleeping. And that is the rub. For people with obstructive sleep apnea, they can stop breathing hundreds of times a night.

This wakes you up, not enough to notice it, but enough to be exhausted the next day. It’s bad for your attention, it’s bad for your blood pressure, and it makes the treatment of ADHD much more difficult. Undiagnosed, OSA could lead to increasing the dose of stimulant, which may lead to difficulty falling asleep, which may make the problem worse.

Treatment:

The solutions for sleep apnea start with an evaluation by a sleep medicine doctor, usually the prescription of a CPAP (constant positive airway pressure) machine that uses air pressure to splint your airway open. I got mine from CPAP.com —which is a domain name that I imagine was expensive.

Losing weight can also reverse the problem.

Not all snoring is obstructive sleep apnea, but it’s a symptom. There are also people who snore and don’t have OSA. I’m looking at you, idiopathic snoring.

My Opinion:

It’s worth treating OSA.

3. Insomnia

Some people have difficulty falling asleep. It’s actually has a specific name, and it’s sleep onset insomnia—often we add the medical term for without other explanation: Idiopathic insomnia.

It’s not idiopathic2 if you can’t sleep cause someone is shaking you every time you almost fall asleep. That would be “jackass-associated insomnia” or something.

And for people with ADHD, whose thoughts tend to race, it can be very difficult to fall asleep. Sleep is a learned behavior, and many of us are training ourselves to not fall asleep. Our own mind— it’s doing the shaking when you have ADHD.

For those of you who are reading this in bed, I’ve got bad news for you, your behavior right now is harmful to restful sleep. But if the doc doesn’t ask, “what’s going on in your mind?,” they may round it off to “idiopathic” and call it a day. For people with ADHD, this is often an unhelpful answer, and 44% of patients with ADHD have associated sleep onset insomnia.

Insomnia Treatment, ADHD Edition:

The best treatment for most chronic insomnia is cognitive behavioral therapy for insomnia. Because it works. CBT-i doesn’t create side effects that interrupt the quality of your sleep.

With CBT-i, you can learn how to sleep again. It is actually better taught by a computer in some studies. There is a commercial and FDA-approved version of this treatment, that’s not a drug, it’s a digital therapeutic. It’s made by a company called Pear Therapeutics, and they named the product Somyrst. It’s prescription app for your phone. Getting insurance companies to pay for it hasn’t been easy—what else is new? There are options if you are uninsured or “functionally uninsured.”

Next Steps:

There are medicines that work for ADHD—clonidine and guanfacine—that are also sedating if you take them in the evening. These medicines help symptoms, and can also help you sleep. These are reasonable choices to discuss if you have ADHD and difficulty sleeping. Even if you don’t have difficulty sleeping, they may be helpful when you don’t want to utilize stimulant medications or want to take them at lower dosages.

Most “sleep medicines” are not good. Highlights include:

Ambien (zolpidem): Hot take: it sucks. People get a few nights of slightly better sleep in a randomized controlled trial (44 min extra on average in the FDA approval trial).

Tolerance develops to the sleep inducing effects very quickly. No tolerance meaningfully develops to the amnestic—forgetting stuff—effects. People end up taking Ambien for years, and forgetting they were staying awake instead of getting more sleep.

Benzodiazepines: these medicines have brand names like Xanax, Klonopin, Valium, Ativan, Restoril.3

Binding to the GABA receptor leads to feeling sleepy. It changes how your brain functions in sleep so that it’s less restful. Ask your doctor before starting—and never stop these meds abruptly. Death and death-related symptoms are what can occur with abrupt benzodiazepine discontinuation.

ADHD: Sleep Matters

These tips should help clarify what three common sleep problems look like with ADHD, and some recommendations about what to do. Attention takes your whole brain, so the care we get needs to take all of our health into account. Sleep disorders are especially important when assessing serious risk for completed suicide, particularly in high risk populations like veterans and first responders.

Thanks for reading!

—O. Scott Muir, M.D.

1

Which breakdown amphetamines but not methylphenidate, which is metabolized in the blood by non-liver enzymes. This is first pass metabolism I’m referring to, not second pass, which is primarily handle by UGT enzymes that allow for the excretion of drug metabolites…in your poop. There are basically two ways we get rid of these things, people.

2

The differential diagnosis includes delayed sleep phase disorder, which is more common.

3

In fact, our friend, Ambien, works on one of the two subunits of the benzodiazepine receptor site (bz 1/bz 2 subunits) on the GABA receptor. Benzodiazepines bind to both. GABA is the primary inhibitory neurotransmitter in the brain. I’ve explained the basics of neuron functioning before, and also explained the difference between “fast acting” neurotransmitters and modulatory neurotransmitters. The anxiety reducing effects of benzodiazepines are modulated by a subunit that also makes them an effective treatment for seizures. The withdrawal from the receptor put you at risk for seizures. You can see why this sucks. The “hypnotic” effects (a.k.a. putting you to sleep) are modulated by the other subunit and thus drugs like Zolpidem and Eszopiclone try to capitalize on this difference to reduce risk profile.

The Frontier Psychiatrists

If You Have ADHD, These Three Problems Might…