August 2013  << Back  

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Complete sleep-wake cycle reversal related to ADHD detected by actigraphy

Rachel E. Fargason, MD

Department of Psychiatry and Behavioral Neurobiology, University of Alabama School of Medicine, Birmingham, AL, USA

Brittny A. White, MS

Department of Psychiatry and Behavioral Neurobiology, University of Alabama School of Medicine, Birmingham, AL, USA

Karen L. Gamble, PhD

Department of Psychiatry and Behavioral Neurobiology, University of Alabama School of Medicine, Birmingham, AL, USA

KEYWORDS: CRSD, ADHD, actigraphy, insomnia


Insomnia often goes untreated despite adverse mood and neurobehavioral effects.1 A key objective in DSM-5 is improved management of sleep disorders comorbid with psychiatric conditions.1 Circadian rhythm sleep disorder (CRSD) occurs in 70% of patients with attention-deficit/hyperactivity disorder (ADHD).2 We present a case of severe CRSD, delayed sleep phase type in a patient with ADHD, which was undetected before actigraphy, to increase clinicians’ awareness of this common, albeit neglected, condition. We also discuss validated actigraphic sleep assessment devices that may help detect this condition. Actigraphy’s advantages over polysomnography have led to increased use of actigraphy in research and sleep clinic settings.3 Actigraphic smartphone applications and commercial accelerometers (Sleep Cycle®, UP Wristband®, Sleep Manager Pro®, The One™FitBitz) are available to the general public.

High sensitivity for circadian measures and sleep-onset/offset times make actigraphy particularly suitable for sleep schedule disorders, such as CRSD.3 Even inexpensive products that detect subtle nighttime movement data from the accelerometer in smartphones can generate graphs of sleep-wake cycles. Validity measures for each device must be assessed individually. Actiwatch is a continuously worn, motion-sensing accelerometer.3 Activity counts are analyzed by software to produce objective sleep quality data and graphs of sleep-wake cycles over weeks.1 Sleep diaries enhance validity.

Case Report

Mr. J, age 31, presents with lifelong complaints of distractibility, restlessness, anergia, fatigue, and academic and social underperformance. Sleep history reveals chronically late bedtimes resulting in shortened sleep, but no associated distress or impairment. Mr. J previously underwent inpatient substance treatment because he used alcohol excessively every night to induce sleep; he has been abstinent of alcohol for a decade. Mental status reveals a fidgety, cheerful, euthymic, slightly tangential man. He was diagnosed at this time with ADHD persisting since early childhood (by DSM-IV-TR) without other psychiatric comorbidity and entered an ADHD-insomnia trial unmedicated.4 Mr. J’s participation in the trial was terminated early because researchers discovered complete sleep-wake cycle reversal by actigraphy. See the FIGURE for displays of one week of Mr. J’s sleep-wake patterns.

FIGURE: Actigraphy studya of CRSD delayed due to ADHD (left) and in a normal control (right)
aActiwatch AW-64 Actigraphy System/Actiware-Sleep version 5.04 Sleep Scoring Software, Philips Respironics, Murrysville, PA; ClockLab Analysis software: Actimetrics, Wilmette, IL.
ADHD: attention-deficit/hyperactivity disorder; CRSD: circadian rhythm sleep disorder.

Mr. J underreported his sleep problems. Patients with insomnia often misperceive their actual sleep states.5 CRSD was exacerbating Mr. J’s dysfunction and needed to be stabilized before treating his ADHD. Circadian disorders can negatively impact work and social performance1; excessive tardiness put Mr. J’s job at risk. ADHD severity correlates positively with circadian delay.2 Most insomnia patients attempt independent treatment using over-the-counter medications or alcohol.1 In Mr. J’s case, untreated CRSD led to self-medication and reliance on alcohol.

We advanced the delayed sleep phase using morning-time light therapy, dim evening lighting, and 8 mg/d of ramelteon—a melatonin agonist with hypnotic and circadian-entraining effects4—taken at the desired bedtime. These measures facilitated a sustained 11 pm bedtime and 8 am rise time. Mr. J’s case is not rare; 8.3% of ADHD-insomnia patients have severe, undetected sleep disorders that can only be discovered with actigraphy.4 Reliable actigraphy instruments inform diagnostic and treatment decisions.

DISCLOSURES: The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

ACKNOWLEDGEMENT: This study was supported by a University of Alabama HSF General Endowment Fund Grant.


  1. Wirz-Justice A, Bromundt V, Cajochen C. Circadian disruption and psychiatric disorders: the importance of entrainment. Sleep Med Clin. 2009;4:273–284.
  2. Gamble KL, May RS, Besing RC, et al. Delayed sleep timing and symptoms in adults with attention-deficit/hyperactivity disorder: a controlled actigraphy study. Chronobiol Int. 2013;30:598–606.
  3. Sadeh A. The role and validity of actigraphy in sleep medicine: an update. Sleep Med Rev. 2011;15:259–267.
  4. Fargason RE, Gamble K, Avis KT, et al. Ramelteon for insomnia related to attention-deficit hyperactivity disorder. Psychopharmacol Bull. 2011;44.
  5. Bianchi MT, Klerman EB. Sleep misperception in healthy adults: implications for insomnia diagnosis. J Clin Sleep Med. 2012;8:547–554.

CORRESPONDENCE: Rachel Fargason, MD, 3rd Floor Callahan Eye Hospital, 1720 University Boulevard, Birmingham, AL 35294 USA, E-MAIL: