Psychiatry Research 291 (2020) 113162

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Adult attention-deficit hyperactivity disorder and clinical correlates of T

delayed sleep phase disorder
Vincenza Speraa, Marco Maielloa, Alessandro Pallucchinia, Martina Novia, Camilla Elefantea,
⁎
Francesco De Dominicisa, Laura Palaginia,b, Joseph Biedermanc,d, Giulio Perugia,b,
a
Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa, Italy
b
Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
c
Massachusetts General Hospital, Boston, United States
d
Harvard Medical School, Boston, MA, United States

A R T I C LE I N FO A B S T R A C T

Keywords: The purpose of the study was to assess the prevalence and clinical correlates of Delayed Sleep Phase Disorder
ADHD (DSPD) in adults with Attention-Deficit/Hyperactivity Disorder. Participants were 102 adults (Female= 27),
Circadian rhythm disorders aged 18-65 (mean age= 28.2 years), with ADHD diagnosed in adulthood. ADHD and DSPD diagnosis were made
Emotional dysregulation according to DSM-5 criteria. Assessing instruments included the Morningness-Eveningness Questionnaire, the
Cannabis
brief Temperament Evaluation of Memphis, Pisa, Paris and San Diego Questionnaire, the Barratt Impulsiveness
Temperaments
Scale, the Reactivity Intensity Polarity Stability Questionnaire-40 and the World Health Organization Disability
Assessment Schedule 2.0. Epidemiological and Clinical features were compared in patients with and without
DSPD. 34 out of 102 patients were classified as having a Delayed Sleep Phase Disorder. As expected, DSPD
patients reported a more frequent evening chronotype. In the multivariate logistic regression analysis, Delayed
Sleep Phase Disorder was significantly associated with young age, cannabis use, cyclothymic temperamental
traits and severe global impairment. An early diagnosis with a proper treatment targeted to both disorders may
be fundamental in order to improve the overall functioning and the outcome of adult ADHD patients.

1. Introduction
Attention deficit hyperactivity disorder (ADHD) is a chronic con-
dition characterized by symptoms of inattention, impulsivity and over-
reactivity that starts in childhood by the age of 12 years. It is estimated
to affect up to 10% of children and 5% of adults worldwide (Centers for
Disease Control and Prevention, 2019) (Kessler et al., 2006). ADHD in
adults is associated with more impairment in academic performance,
work functioning (Biederman et al., 2006) and higher rates of psy-
chiatric comorbidities (Kessler et al., 2006). In the last decades, a
growing interest in sleep problems in ADHD patients has led to an in-
creasing body of literature, which is trying to shed light on the asso-
ciations between the two disorders. A recent metanalysis (Diaz-
Roman et al., 2018) focusing on the subjective and objective sleep
parameters that differentiate subjects with and without ADHD found
that the formers have an increased sleep latency onset and lower sleep
efficiency and quality. Sleep disturbances may occur in up to 83%
(Fisher et al., 2014; Sobanski et al., 2008) of adults with ADHD who
display more primary sleep disorders, longer sleep onset latency and
insomnia (Kooij et al., 2001; Wynchank et al., 2017). The coexistence of
sleep disorders with ADHD not only adds significant morbidity, causes
more cognitive and behavioural problems, excessive daytime fatigue,
functional impairment and a reduced quality of life, but also increases
impulsivity and worsens attention deficits (Biederman et al., 2007;
Wajszilber et al., 2018). Sleep disorders in adult ADHD patients have
been closely related to circadian rhythms dysregulation
(Wajszilber et al., 2018). Circadian rhythms, involved in the sleep/
wake cycle, are patterns of near 24-hour consisting of cyclic variations
of biological oscillations generated by a circadian pacemaker located in
the hypothalamic suprachiasmatic nuclei (SCN). It has been shown that
the majority of individuals with ADHD present different kinds of al-
terations in the circadian rhythmicity which have been related to a
decrease in the volume of the pineal gland, and/or clock gene ab-
normalities regulating the activity of the circadian pacemaker (van der
Heijden et al., 2005; Van Veen et al., 2010).
The majority of the studies have focused on circadian preference, or
chronotype, (preferred time of rest/activity) in adults with ADHD, re-
porting high rates of late circadian preference (‘evening chronotype’)

⁎
Corresponding author.
E-mail address: giulio.perugi@med.unipi.it (G. Perugi).

https://doi.org/10.1016/j.psychres.2020.113162
Received 4 December 2019; Received in revised form 26 May 2020; Accepted 29 May 2020
Available online 03 June 2020
0165-1781/ © 2020 Elsevier B.V. All rights reserved.
V. Spera, et al.
(Coogan and McGowan, 2017; Rybak et al., 2007). Evening chronotype
has been associated with short sleep duration and higher rates of
physical illnesses such as hypertension, obesity and other metabolic
diseases (Yu et al., 2015). In a study (Bae et al., 2010), ADHD males
with an evening chronotype reported more symptoms of inattention,
impulsivity-hyperactivity, whilst in females eveningness was correlated
with inattention but not with impulsivity-hyperactivity; both gender
reported an overall increased severity of ADHD symptomatology. An-
other study, focused on different ADHD subtypes, showed that the
combined-type was associated with more circadian rhythms problems
when compared to the inattentive-type; conversely this latter was as-
sociated with hypersomnia (Chiang et al., 2010). Overall, eveningness
has shown to be positively correlated with the severity of ADHD
symptomatology (Arendt, 2000; Bae et al., 2010).
Among the circadian alterations, Delayed Sleep Phase Disorder
(DSPD), characterized by a chronic pattern of delayed bedtimes and
wake times compared to the desired times, is the most frequent circa-
dian rhythm disorder seen in ADHD subjects (Kooij and Bijlenga, 2013;
Snitselaar et al., 2017) with a prevalence rate of about 78% in adult
populations (Van Veen et al., 2010). A DSPD prevalence of 26% has
been observed using self-reports (Bijlenga et al., 2013). This figure is
much higher than that reported in the general population, where the
range varies between 0.1 and 3.1%(Kooij and Bijlenga, 2013). Although
some studies have been conducted on the relationship between circa-
dian rhythm alterations and ADHD clinical features, the field is still
lacking of evidence, in particular in adult subjects. Hence, in the pre-
sent study we aimed to assess the prevalence and the clinical impact of
DSPD in a sample of adult subjects with ADHD diagnosed and treated
for the first time during adulthood.
2. Methods
2.1. Sample and assessment
This is a naturalistic, observational study based on a single eva-
luation of 102 adult patients (F= 27) aged 18-65 (mean age= 28.2
years) with a clinical diagnosis of ADHD according to the Diagnostic
and Statistical Manual of Mental Disorders, 5 edition (DSM-5) (2013),
admitted between 2016 and 2019 to the Outpatient Unit of the
Psychiatric Unit of the University of Pisa. All the patients recruited in
the study were diagnosed and treated for the first time in adulthood,
after 18 years of age. This population is particularly interesting for the
study of the “natural” evolution in adulthood of different subtypes of
untreated ADHD. All patients were evaluated with clinical interview
and specific diagnostic tests by residents (A.P, M.M, V.S, M.N, C.E, F.D.)
with at least 2 years of experience at ADHD Outpatient Clinic of the
Department of Clinical and Experimental Medicine, Section of
Psychiatry, of the University of Pisa, under the supervision of senior
psychiatrists (GP).
ADHD screening was conducted using the Adult ADHD Self Report
Scale (ASRS) (Kessler et al., 2005), and the Conners’ Adult ADHD
Rating Scales–Observer: Short Version (CAARS-O:S) (Conners CK,
1999). If these tests were suggestive of an ADHD diagnosis, the DIVA
2.0 (Diagnostic Interview for ADHD in adults) (Kooij, 2013), was used
to assess the presence of the disorder. The Structured Clinical Interview
for Axis I Disorders (SCID-I) was used for the evaluation of other psy-
chiatric disorders, according to DSM-5. All the ADHD patients under-
went a clinical interview with a certified sleep medicine psychiatrist
(LP) to establish Delayed sleep phase disorder (DSPD) diagnosis, ac-
cording to DSM-5 criteria. Patients chronotype was evaluated by means
of the Morningness-Eveningness Questionnaire (MEQ). MEQ is a self-
assessment questionnaire composed of 19 items: a score of 41 and
below indicates an ‘evening chronotype’ (Horne and Ostberg, 1976). A
demographic anamnestic scale was used to collect the participants'
demographic and clinical data. The brief Temperament Evaluation of
Memphis, Pisa, Paris and San Diego-M (TEMPS-M) (Erfurth et al., 2005)
2
Psychiatry Research 291 (2020) 113162
was used to measure five affective temperaments known as depressive,
cyclothymic, hyperthymic, irritable and anxious. The Barratt Impul-
siveness Scale (BIS-11) (Patton et al., 1995) is a 30 items questionnaire
used for the assessment of impulsiveness, which is factorialized into
three second order domains named Attentional, Motor and Non-plan-
ning impulsivity. The Reactivity Intensity Polarity Stability Ques-
tionnaire (RIPoSt-40) (Brancati et al., 2019) is a self-report ques-
tionnaire of 40 items used to measure emotional dysregulation (ED)
that could be further subdivided into four subscales known as Emo-
tional impulsivity, Positive emotionality, Negative emotionality and
Affective instability. The World Health Organization Disability Assess-
ment Schedule (WHODAS 2.0) (2010), developed by the World Health
Organization, is a 36-items self-administered questionnaire useful to
explore functioning and disability in major life domains due to a mental
health condition. For clinical variables comparisons, the ADHD sample
was then divided in a group affected by Delayed sleep phase disorder
(DSPD) and a group without DSPD (N-DSPD).
The study was conducted according to the Declaration of Helsinki
and was approved by the local Ethic Review Board of the University
Hospital of Pisa. All participants provided written informed consent
prior to being enrolled in the study.
2.2. Data analysis
We compared demographic characteristics and clinical features in
ADHD adults with and without DSPD. Descriptive analyses were re-
ported in terms of mean and standard deviations for continuous vari-
ables and number and percentages for categorical ones. Comparisons
between the two groups were conducted using chi-square test for ca-
tegorical variables (Fisher exact test when appropriated) and Student's
t-test for continuous variables (Mann-Witney U test when appro-
priated). Given the exploratory nature of our studies, the significance
level for each test was established at p < 0.05. To identify the pre-
dictive value of the characteristics of ADHD patients on DSPD, a step-
wise backward logistic regression model was carried on. An alpha of
0.05 in the univariate comparison was utilized as the cut-off for the
inclusion of a variable in the regression model. We used the statistical
routines of IBM SPSS Statistics for Macintosh, Version 25.0.
3. Results
3.1. Sample characteristics and ADHD subtypes
Of the 102 ADHD patients recruited, 75 (73.5%) were males and 27
(26.5%) females with a mean age of 28.2 ± 10.32 years. Thirty-four
(33.3%) met DSM-5 criteria for DSPD. Table 1 shows comparisons be-
tween DSPD and N-DSPD groups regarding demographic character-
istics. The DSPD group was significantly younger compared to the N-
DSPD group (t=3.08; p=0.003). We did not observe a significant dif-
ference regarding gender distribution (chi square=0.91; p=0.341),
attended years at school (t=0.18; p=0.856) and number of school
flunks (t=1.11; p=0.270) between the two groups. At the DIVA 2.0
scale, no differences were found between DSPD and N-DSPD in terms of
ADHD subtypes (chi-square=0.42; p=0.813). At the CAARS-O:S,
completed by a close patient's relative, DSPD patients were similar at
Inattentive (t=-0.85; p=0.399), Hyperactivity/Impulsivity (t=-0.82;
p=0.413), Combined (t=-0.99; p=0.323) symptomatology and at the
CAARS index (t=-1.91 p=0.236) to N-DSPD patients (Table 1). As
expected, DSPD patients scored lower on the MEQ scale (41.02 ± 10.69
vs. 50.42 ± 12.20; t=3.81; p<0.000), which indicates a high fre-
quency of evening chronotype (Table 3).
3.2. Psychiatric comorbidities
There were no between-group differences in terms of Bipolar spec-
trum disorders (chi-square=0.00; p=1.000), Cyclothymic disorder
V. Spera, et al. Psychiatry Research 291 (2020) 113162

Table 1 Table 3
Demographic characteristics and ADHD subtypes in ADHD patients with DSPD Psychopathological features of ADHD patients with DSPD and without DSPD
and without DSPD (N-DSPD) (N-DSPD)
N-DSPD N=68 DSPD N=34 t/χ2 p N-DSPD N=68 DSPD N=34 t/χ2 p
Mean ± SD Mean ± SD RIPoSt-40 N(%) N(%)
Age 30.10 ± 10.88 24.18 ± 8.02 3.08 0.003 RIPoSt total score 29 (42.6) 21 (61.8) 3.31 0.069
N(%) N(%) Mean ± SD Mean ± SD
Female gender 20 (29.4) 7 (20.6) 0.91 0.341 Affective instability 41.31 ± 11.33 46.38 ± 13.21 -2.01 0.047
Attended years at 13.49 (3.54) 13.30 (2.43) 0.18 0.856 Positive emotionality 40.17 ± 9.31 41.50 ± 8.44 -0.70 0.485
school Negative emotionality 38.15 ± 10.25 40.56 ± 9.25 -1.16 0.250
Number of flunking out 1.15 (1.06) 0.91 (1.10) 1.11 0.270 Emotional impulsivity 28.83 ± 8.57 32.88 ± 8.54 -2.25 0.026
of school TEMPS-M
ADHD subtypes (DIVA Depressive 21.12 ± 5.57 22.06 ± 6.07 -0.78 0.437
2.0) Cyclothymic 21.82 ± 6.30 25.68 ± 7.21 -2.78 0.007
-combined 50 (73.5) 23 (67.6) 0.42 0.813 Hyperthymic 20.10 ± 6.04 22.56 ± 5.26 -2.02 0.046
-inattentive 12 (17.6) 7 (20.6) Irritable 18.85 ± 6.35 23.09 ± 6.92 -3.09 0.003
-hyperactive/ 6 (8.8) 4 (11.8) Anxious 16.02 ± 5.98 17.94 ± 6.41 -1.49 0.138
impulsive WHODAS 2.0
CAARS-O:S WHODAS total score 88.19 ± 26.80 101.79 ± 23.20 -2.52 0.013
Mean ± SD Mean ± SD BIS-11
-inattentive 17.68 ± 5.29 18.62 ± 5.29 -0.85 0.399 Attentional 2° order 20.77 ± 3.55 22.74 ± 4.39 -2.44 0.017
-hyperactive/ 14.65 ± 6.01 15.74 ± 6.71 -0.82 0.413 Motor 2° order 27.44 ± 5.97 28.59 ± 5.13 -0.96 0.340
impulsive Non planning 2° order 32.06 ± 5.14 31.96 ± 5.06 0.08 0.930
-combined 32.31 ± 9.46 34.35 ± 10.48 -0.99 0.323 MEQ total score 50.42 ± 12.20 41.02 ± 10.69 3.81 0.000
-CAARS Index 23.04 ± 5.80 24.50 ± 5.86 -1.91 0.236
Notes: RIPoSt-40=Reactivity, Intensity, Polarity and Stability questionnaire;
Notes: DIVA 2.0= Diagnostic Interview for ADHD in adults; CAARS-O:S= TEMPS-M= brief Temperament Evaluation of Memphis, Pisa, Paris and San
Conners’ Adult ADHD Rating Scales–Observer: Short Version. Diego-M; WHODAS 2.0=World Health Organization Disability Assessment
Schedule 2.0; BIS-11= Barratt Impulsiveness Scale; MEQ=Morningness-
Table 2 Eveningness Questionnaire.
Psychiatric comorbidities in ADHD patients with DSPD and without DSPD (N-
DSPD) Table 4
Multiple logistic regression of clinical features on the presence of DPSD in
N-DSPD N=68 DSPD N=34 t/χ2 p
N(%) N(%) subjects with Adult-ADHD
Bipolar spectrum disorders 46 (67.6) 23 (67.6) 0.00 1.000 Variables in equation Wald p-value OR (95% CI)
Cyclothymic disorder 13 (19.1) 7 (20.6) 0.03 0.860 Cyclothymic temperament 4.070 .044 1.090 (1.002-1.185)
Borderline personality disorder 22 (32.4) 14 (41.2) 0.77 0.379 Age 8.203 .004 .908 (.850-.970)
Substance use disorder 31 (45.6) 19 (55.9) 0.96 0.327 WHODAS 2.0 3.961 .047 1.022 (1.000-1.044)
-Cannabis use disorder 15 (22.1) 17 (50.0) 8.22 0.004 Cannabis use 5.747 .017 3.436 (1.252-8.386)
Panic attack disorder 14 (20.6) 4 (11.8) 1.21 0.270
Obsessive-compulsive disorder 5 (7.4) 2 (5.9) 0.08 0.782
Variables not in equation: Irritable Temperament; RIPoSt Emotional
Generalized anxiety disorder 26 (38.2) 11 (32.4) 0.34 0.560
Impulsivity; RIPoSt Affective Instability; RIPoSt total; BIS Attentional 2nd
Social phobia 6 (8.8) 3 (8.8) 0.00 1.000
Eating disorders 13 (19.1) 4 (11.8) 0.88 0.348 Order.
Chi-square: 28.396; df: 4; p<.000
Notes: WHODAS 2.0=World Health Organization. Disability Assessment
(chi-square= 0.03; p=0.860), Panic disorder (chi-square=1.21; Schedule 2.0; RIPoSt=Reactivity, Intensity, Polarity and Stability ques-
tionnaire; BIS=Barratt Impulsiveness Scale.
p=0.270), Generalized anxiety disorder (chi-square=0.34; p=0.560),
Social phobia (chi-square=0.00; p=1.000), Obsessive Compulsive
3.4. Correlates of DSPD in ADHD
disorder (chi-square=0.08; p=0.782), Eating disorders (chi-
square=0.88; p=0.348), Borderline personality disorder (chi-
Backward stepwise logistic regression was carried to identify the
square=0.77; p=0.379), Substance use disorders (chi-square=0.96;
features that differentiated ADHD patients with and without DSPD. As
p=0.327) across the two groups (Table 2). Among the substances used,
shown in Table 4, we found that DSPD patients were characterized by
subjects with DSPD were more likely to use Cannabis compared to N-
having a cyclothymic temperament (p=0.044), a younger age
DSPD (chi-square=8.22; p=0.004)(Table 2).
(p=0.004), a cannabis use (p=0.017) and a greater functional im-
pairment (p=0.047). These four factors correctly classified 76.2% of
cases.
3.3. Temperamental and psychopathological features

Regarding affective temperaments measured by TEMPS-M scale, 4. Discussion

DSPD patients showed higher scores in cyclothymic (t=-2.78;
p=0.007), hyperthymic (t=-2.02; p=0.046) and irritable (t=-3.09;
p=0.003) temperamental subscales compared to N-DSPD ones. DSPD
patients also showed a statistical significant higher score than N-DSPD
ones in the BIS Attentional second order domain (t=-2.44; p=0.017),
in the RIPoSt-40 Affective instability subscale (t=-2.01; p=0.047) and
Emotional impulsivity subscale (t=-2.25; p=0.026). Finally, DSPD
patients were more functionally impaired than N-DSPD as highlighted
by the WHODAS 2.0 total score (t=-2.52; p=0.013)(Table 3).
In the present study, we systematically evaluated the prevalence
and clinical features associated with DSPD in patients with ADHD di-
agnosed and treated for the first time in adulthood. In our sample, male
gender (73.5%) was more represented than the female one (26.5%) and
this is slightly in contrast with the prevalence rates reported in litera-
ture, where most studies show a more balanced gender distribution in
ADHD adults (Biederman et al., 2004). This discrepancy might be ex-
plained by differences in the sampling procedure. The majority of our
ADHD patients are referred to the psychiatric evaluation for hetero-
genous psychiatric complaints and had never been diagnosed or treated
for ADHD during childhood. Males with ADHD frequently display

3
V. Spera, et al.
externalizing disorders with impulsive behaviours, which directs the
clinician toward the possible diagnosis of ADHD, whilst in females in-
attentive and emotional/affective symptomatology predominates, or-
ienting towards a diagnosis of personality disorder.
In line with the existing literature (Coogan and McGowan, 2017;
Kooij and Bijlenga, 2013; Snitselaar et al., 2017) DSPD is very common
in our adults with ADHD and was present in 1 patient out of 3. Our
results suggest a distinct profile of ADHD individuals that are affected
by DSPD. ADHD-DSPD patients were younger, reported more frequently
cyclothymic temperament and cannabis use and showed greater im-
paired global functioning compared to ADHD adults without the cir-
cadian rhythm disorder. In our patients DSPD does not correlate with a
specific ADHD subtype. This is in contrast with other reports
(Chiang et al., 2010) who showed more circadian rhythm disorders in
ADHD children and adolescents with combined type than the ones with
inattentive type. However, a recent study, assessing ADHD symptoms in
adults affected by DSPD, revealed that the circadian rhythm disorder
was associated with an increased severity of ADHD symptomatology in
both inattentive and hyperactive/impulsivity domains compared to
non-DSPD subjects (Snitselaar et al., 2019). Finally, although literature
results are mixed, evening circadian preference in ADHD individuals
seems to be correlated with attentional difficulties, impulsivity and
high prevalence of DSPD (Coogan et al., 2016).
In our sample, younger adults with ADHD had significant more
DSPD compared to the older ones. This result is in line with the finding
that an evening chronotype is common in young patients, while around
the fourth decade of life, the sleep/wake cycle naturally moves back-
wards to an earlier chronotype (Roenneberg et al., 2004). On the other
hand, a study (Bijlenga et al., 2013) comparing ADHD patients to
healthy controls found that DSPD was equally present in younger and
older subjects with ADHD and significantly more common than in the
control population, suggesting that DSPD in some adult populations
might not be age-related.
As concern temperamental assessment, in our sample we found a
significant association between DSPD and affective temperaments:
specifically cyclothymic, hyperthymic and irritable temperamental
subscales. So far, no literature study explored the associations among
adult ADHD, DSPD and affective temperaments and only few studies
evaluated temperamental traits in adults with ADHD. Previous studies
showed greater affective temperamental traits in ADHD subjects
(Landaas et al., 2012) which may increase the vulnerability to the
subsequent development of mood and anxiety disorders. A controlled
study found a higher prevalence of cyclothymic, irritable, depressive
and anxious temperaments in both ADHD and Bipolar Disorder patients
compared to healthy controls; specifically the ADHD group showed a
more frequent cyclothymic and irritable temperament in addition to
higher impulsivity traits (Torrente et al., 2017). Similarly, a Norwegian
study (Landaas et al., 2012) found more cyclothymic temperamental
traits (TEMPS-A) in adult ADHD patients associated with more severe
ADHD manifestations and more psychiatric comorbidities compared to
healthy controls. Similarly, higher rates of cyclothymic, depressive, ir-
ritable and anxious temperaments were reported in healthy young
subjects with an evening chronotype, while morning chronotype was
associated with higher hyperthymic temperament (Park et al., 2015).
As a general conclusion, most of the literature consistently indicates a
relationship between cyclothymic traits and evening chronotype.
Similarly, our ADHD patients with DSPD scored significantly higher
at Affective instability (p=0.047) and Emotional Impulsivity
(p=0.026) subscales of the RIPoSt-40 Emotional Dysregulation scale.
These two subdomains respectively reflect mood fluctuations and dif-
ficulty to regulate emotional and behavioural responses. Various stu-
dies conducted both in children and adults have shown a strong link
between ADHD and emotional dysregulation (ED). ED prevalence in
adults is estimated between 30% and 70% (Shaw et al., 2014) and has
been associated with a more persistent ADHD course, a higher co-
morbidity with affective and personality disorders (Dadomo et al.,
4
Psychiatry Research 291 (2020) 113162
2016) (Shaw et al., 2014) representing a transnosographic feature of
different mental health conditions. Previous studies have demonstrated
how sleep disorders negatively affect the processing and the regulation
of emotions. The neurobiological underpinnings are related to a de-
creased control of the medial prefrontal cortex and the ventral anterior
cyngulate cortex on the amygdala caused by sleep disruption thus
further worsening the deficit in emotional regulation which is prevalent
in many ADHD patients (Shaw et al., 2014) (Palagini et al., 2019). As
expected our ADHD patients with DSPD displayed more attentional
impulsiveness (BIS-11), which is considered a tendency to make quick
cognitive decisions and a measure of the ability to concentrate. This
finding could depend on the combined effect of ADHD symptomatology
and the consequences of DSPD on everyday functioning. In fact, DSPD is
known to affect cognitive function during waking hours, leading to
sleepiness and easy distractibility, which recall the symptoms of ADHD.
Overall, the raised occurrence of temperamental traits, mostly cy-
clothymic, added to the emotional difficulties and cognitive impul-
siveness in our ADHD-DSPD patients could delineate a particular sub-
group with a greater risk of emotional instability and affective
disorders.
Regarding substances use, our ADHD-DSPD patients reported more
frequently cannabis use compared to the N-DSPD group. To our
knowledge, no previous study investigated substance use prevalence in
ADHD patients with DSPD. Nonetheless, other studies focusing on the
influence of circadian rhythm on substance use have highlighted a
greater use of illegal substances (THC, cocaine, etc.) among subjects
with an evening type circadian preference (Kervran et al., 2015).
The results of the studies on the effect of cannabis on sleep have led
to mixed results. While some found a decreased sleep onset latency
(Cousens and Dimascio, 1973) and fewer awakenings (Pivik et al.,
1972), others failed to reach the same results and observed a reduced
REM sleep (Feinberg et al., 1976; Feinberg et al., 1975; Pivik et al.,
1972) and an increase in slow wave sleep (Schierenbeck et al., 2008).
Even if cannabis use may give a temporary relief from sleep problems
(Chait, 1990), in the long run it is associated with poor sleep quality
and insomnia (Conroy et al., 2016). Also, chronic use could create
adaptation (Schierenbeck et al., 2008), with the need to increase the
dosage and the risk of a more harmful pattern of substance use and
sleep-related withdrawal symptoms (Gates et al., 2016), which could
hinder cannabis use interruption. The increased use of cannabinoids by
ADHD patients with DSPD could be an attempt to adjust their circadian
rhythm to their everyday needs and to contrast the sleep onset insomnia
that often coexists with DSPD. On the other way, young people with a
persistent evening chronotype may be more exposed to night-time ac-
tivities, among which alcohol and substances use.
Our observation of a greater functional impairment (WHODAS 2.0)
in ADHD patients with DSPD is in line with the existing literature.
Disability in DSPD is frequently associated with sleep reduction, day-
time sleepiness, reduced motivation and goal directed activity, which
may favour familial, work and social impairment. The impact of DSPD
on daily functioning increases the importance of early diagnosis and
targeted treatment for the two disorders. Limitations: this is a cross-
sectional study, carried out with adult ADHD patients followed in a
naturalistic setting, lacking a control group; in order to generalize our
results, concerning DSPD prevalence and associated features, future
longitudinal studies are needed with a controlled design. In the present
study, the presence of DSM-5 diagnostic criteria for DSPD was assessed
in a cross-sectional interview by a psychiatrist with a huge experience
in sleep disorders. A more specific DSPD evaluation should be carried
on through a one-week prospective daily sleep diary, in order to collect
subjective data regarding sleep issues and daytime functioning, and by
the use of actigraphy for the objective measure of the rest and activity
patterns.
V. Spera, et al.
5. Conclusions
Overall literature on DSPD in ADHD is scarce and, so far, did not
focus on the clinical implications of the comorbidity between the two
conditions. Our study gives a broader understanding of the phenoty-
pical presentation of ADHD and DSPD, which are very commonly en-
tangled to each other. In particular in our adults with ADHD diagnosed
for the first time after 18 years of age we found a correlation between
young age, cyclothymic traits and related emotional dysregulation,
cannabis use and DSPD. The presence of DSPD seems to further increase
the functional disability in this population, highlighting the importance
of early diagnosis and targeted treatment approach.
The therapeutic strategies for DSPD in ADHD patients consist of
psychoeducation, sleep hygiene, bright light therapy and, among the
pharmacological interventions, the use of melatonin (Kooij and
Bijlenga, 2013). Stimulant treatment has also shown benefits in symp-
toms of insomnia and circadian rhythm disorders of ADHD patients.
Thus, a prompt combined pharmacological treatment for ADHD and
DSPD is important to reduce the burden of comorbidities and amelio-
rate the functional outcome.
Authors contributions
Conceptualization, G.P., Statistical analysis and data interpretation,
G.P., Investigation A.P., M.M., V.S., M.N., C.E., F.D.D., L.P., Writing-
original draft, V.S. and M.M., Writing-Review and editing, G.P., J.B.,
L.P.
Role of the funding source
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
No conflict of interest exists.
Acknowledgements
None
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