The relationship between schizophrenia and sleep disorders is both complicated and crucial.

Research suggests similar gene expressions in both schizophrenia and sleep and circadian rhythm disruption (SCRD), supporting the inclusion of sleep disorders as a symptom of schizophrenia.1 While there is an understandable focus on treating psychosis in those with schizophrenia, treating sleep dysfunction should be an additional and primary concern for clinicians as well.

In fact, in a person with a higher risk of developing schizophrenia (ie, those with a first or second relative) sleep disorders can be an important warning sign – even in stable patients. Symptoms of sleep disruption can predict the onset of positive psychotic symptoms, such as paranoia and hallucinations. During the prodromal phase of schizophrenia, sleep disorders are the most commonly reported symptom and, among those with diagnosed schizophrenia, insomnia is the most widely reported sleep disorder.2,3

“What we are left with is a series of correlations,” says Zachary Freyberg, MD, PhD, an assistant professor of psychiatry and cell biology at the University of Pittsburgh, who completed his fellowship in schizophrenia research at Columbia University. “Both things are happening, but they aren’t necessarily linked through one mechanism….

…What we can say, is that sleep disturbances exacerbate the symptoms of schizophrenia and that schizophrenia is linked with sleep disorders.”

Schizophrenia and Sleep Disorders: Neurochemical Components

SCRD occurs in up to 80% of individuals living with schizophrenia and is associated with schizophrenia symptom severity and a decreased quality of life. People with schizophrenia may also experience alterations to their physiological circadian parameters, such as body temperature and rhythmic hormone production.1

Dopamine

Dopamine seems to play a role in insomnia and dysregulation of the dopaminergic system is seen as the driving force behind schizophrenia.3 Overactivity of dopamine D2 receptors in the striatum has been associated with the positive symptoms of schizophrenia – namely, hallucinations, delusions, disorganized thoughts, and behavioral changes. The same overactivity of D2 receptors has been indicated in insomnia.

One study, led by NIDA Director Dr. Nora D. Volkow, found that just one night’s sleep deprivation increased dopamine levels in the striatum (measured by changes in D2 receptor availability). The researchers believe that this hyperstimulation of D2 receptors in the striatum contributed to study participants’ poor performance on visual learning tasks, suggesting the negative impacts on sleep deprivation and excessive dopamine activation on cognition.4

While dopamine is thought of as the primary neurotransmitter involved in schizophrenia (and is the target of alterations in glutamate, GABA, acetylcholine and serotonin may also be involved in the pathology of schizophrenia.5 Second-generation antipsychotics (SGAs) target serotonin receptors in addition to the D2 dopamine receptor. (More on the difference between first- and second-generation antipsychotics in our clinical primer.)

Dimitri Markov, MD, a sleep specialist at Jefferson Philadelphia Hospital, adds that “There is a lot of overlap between neurotransmitters related to sleep and neurotransmitters involved in schizophrenia. Those neurotransmitters which we might call sleep neurotransmitters are not necessarily just involved in sleep, they’re also transmitters involved in anxiety, depression, psychosis, pain, and satiety.”

The Problem of Poor Sleep in Patients with Psychosis

As noted, poor sleep can directly exacerbate the cognitive symptoms of schizophrenia, such as disorganized thought and/or attention,6 which can then make medications seem ineffective “Antipsychotics help with the auditory hallucinations but they have no effect on the cognitive symptoms of schizophrenia,” explains Dr. Freyberg.

A study of 255 chronic, stable patients with schizophrenia found that 36% had at least one type of insomnia, and these patients reported significantly poorer quality of life, as measured by the World Health Organization Quality of Life Schedule-Brief.7

While researchers cannot confidently point to the exact mechanisms that link sleep and schizophrenia, they do recognize that poor sleep quality negatively impacts psychosis, as well as cognitive functioning and markers of physical health.

Recognizing Signs of Sleep Disorders and their Effects on the Patient

Given that sleep dysfunction can worsen health outcomes in people with schizophrenia and prompt auditory hallucinations, it’s important for the clinician to identify signs of sleep disorders early on.

Explains Dr. Freyberg, “The vast majority of patients with schizophrenia exhibit disrupted sleep architecture, often presenting as reduced latency REM sleep, fragmented circadian rhythms, and more time spent sleeping.”

In addition to regularly discussing a patient’s sleep habits, including issues with daytime sleepiness and other changes in sleep – particularly when beginning a new antipsychotic treatment – clinicians can watch for symptoms of insomnia, sleep apnea, and restless legs syndrome (RSL).

Insomnia

Insomnia may present as: difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening with the inability to go back to sleep.3 Typically, these signs persist for more than 3 months and occur more than 3 times per week. However, poor sleep – even for a short duration – can negatively impact a person’s health and should be addressed.

Sleep Apnea

Obstructive sleep apnea (OSA) is also common in people with schizophrenia, with a meta-analysis reporting a prevalence of 15.4% in this population.8 This rate of OSA may be related to the increased rates of obesity and cardiovascular morbidity that is seen in patients with schizophrenia. Antipsychotics can also increase the risk of developing OSA. Using the BANG screening questionnaire for OSA risk, researchers identified an increased risk in patients taking: risperidone (69%), olanzapine (36 %), and fluphenazine (25%).9

Restless Leg Syndrome (RLS)

RSL is another commonly reported sleep disorder in patients with schizophrenia. Antipsychotics have been linked to RSL via their blocking of D2 receptors. Dopamine agonists may be used to treat RSL.2

Other sleep-related red flags patients are reading about on our Psycom consumer site.

How to Treat Sleep Disorders in Patients with Psychosis

Treating psychosis is often part of treating a sleep disorder, says Dr. Markov. As psychosis improves, sleep often improves as well. While it may seem like a chicken or egg situation, he notes, which came first is not necessarily the most important factor.

Adds Dr. Freyberg, “It’s less important to understand the mechanisms because the mechanisms of both sleep regulation and schizophrenia are unclear, however, there are many practical things that we can do to improve sleep and sleep quality.”

Cognitive Behavioral Therapy

For starters, Dr. Freyberg points to cognitive behavioral therapy (CBT) as an option. One survey of patients with schizophrenia and sleep disorders preferred CBT to sleep medications.10 Another small study of 50 patients found that CBT combined with standard care (medication and contact with a clinician team) was more successful at treating insomnia than standard care alone. After 12 weeks, 41% of patients receiving CBT and standard care no longer reported symptoms of insomnia, compared to just 4% of those patients receiving standard care alone.11

CBT as a tool for managing sleep disorders may be individualized for each patient based on their particular sleep problem(s) and needs. The components of CBT for sleep disorders typically include:12

  • Stimulus control therapy helps to remove factors that condition the mind to resist sleep. For example, a person may be coached to schedule a consistent sleep time and wake time. It is also recommended that the bed be used only for sleep and sex.
  • Sleep restriction reduces the time a person spends in bed, causing partial sleep deprivation, which makes them more tired the next night. Once sleep has improved, time in bed is gradually increased.
  • Sleep hygiene involves changing basic lifestyle habits that influence sleep, such as smoking or drinking too much caffeine late in the day, drinking too much alcohol, or not getting regular exercise.
  • Sleep environment improvement focuses on creating a comfortable sleep atmosphere, which often means a bedroom that is quiet, dark, and cool.
  • Relaxation training teaches techniques that help calm the mind and body.
  • Remaining passively awake, also called paradoxical intention, involves avoiding any effort to fall asleep.
  • Biofeedback enables the patient to observe biological signs, such as heart rate and muscle tension, that affect sleep teaches the patient how to adjust them.

Medication

Dr. Markov stresses that while CBT can be helpful in addressing sleep disorders, the technique is unlikely to mitigate psychotic thinking, which itself can interfere with sleep. Just as sleep medications are sometimes used in the general population, sleep medications may be used to treat patients with schizophrenia and concurrent sleep problems, as long as there are no contraindications.

A few things to consider when prescribing for sleep disorders in patients with psychosis:

  • Sleep medications that are stimulants should not be used as they can induce psychosis
  • Certain antipsychotics used to treat schizophrenia may cause drowsiness and may be recommended for patients who have trouble falling asleep, if these medications are effective in the patient. It may be beneficial to take these medications at night, rather than during the day, as they can aid the patient in falling asleep, advises Dr. Markov.
  • Medical cannabis is not recommended as it can trigger and worsen psychosis in those diagnosed with schizophrenia as well as in those with an increased risk for developing schizophrenia. (See our report on medical marijuana and schizophrenia.)
  • Some antipsychotics can interfere with sleep, even (and sometimes especially) if they have a sedative effect. For example, first-generation antipsychotics are sometimes associated with RLS, whereas second-generation or atypical antipsychotics are more often associated with improved sleep and less neurological side effects.13 However, each drug is slightly different and will interact uniquely with each patient. As an example, in one study of second-generation antipsychotics, both olanzapine and risperidone increased slow-wave sleep in subjects with schizophrenia and improved sleep quality despite olanzapine sometimes being associated with a rise in RLS.14
  • Consistent monitoring and communication with the patient is a key factor when prescribing antipsychotics.

Professional Takeaways

Overall, Dr. Freyberg emphasizes that when starting a patient on antipsychotics, it is particularly important to discuss and monitor sleep habits and to intervene with CBT if necessary and possible. “Lack of insight into the disease is a compounding complication,” he explains. “The person with schizophrenia does best with comprehensive care and a support network, which should include: regular input from a psychiatrist, social and familial support structures, therapy to address cognitive symptoms, and group therapy.”

Since antipsychotics help to address the positive symptoms of schizophrenia but do not target the negative or cognitive symptoms of the disorder, both Dr. Freyberg and Dr. Markov agree that none of these approaches are truly effective in isolation – a comprehensive approach is crucial.

 

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References
Last Updated: Nov 18, 2020