Analyze the following scenario and identify the class of substance most likely responsible for the described sleep disorder. Justify your answer by explaining how the patient's symptoms align with the typical effects of this substance class during both intoxication and withdrawal.

Analyzing Sleep Disturbance Patterns

Amphetamine substances and other stimulants are characterized by insomnia during intoxication and excessive daytime sleepiness during withdrawal. 

With MDMA ("ecstasy")-related substances, individuals may feel restless and experienced sleep disturbances within 48 hours of intake, followed by persisting symptoms of anxiety and depression, even if taken after a long period of abstention.

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Classes of substances and medications that invoke severe sleep disturbances and can occur in association with intoxication and withdrawal include:
- Alcohol
- Caffeine
- Cannabis
- Opioids
- Sedatives, hypnotics, or anxiolytics
- Stimulants (i.e. cocaine)
- Tobacco (only with substance withdrawal, not intoxication)
- Unknown (any substance/medication not listed above that likely affects the central or autonomic nervous systems)

Substances and Medications Related to Substance/Medication-Induced Sleep Disorder

American Psychiatric Association Publishing. (2022). Non–Rapid Eye Movement Sleep Arousal Disorders. In Diagnostic and statistical manual of mental disorders, fifth edition text revision: DSM-5-TR (5th ed., pp. 469–475). section.

Substance/Medication-Induced Sleep Disorder from the DSM-V

Spielman, R. M., Jenkins, W. J., & Lovett, M. D. (2020, April 22). Psychology (2nd ed.). OpenStax. https://openstax.org/books/psychology-2e/pages/1-introduction

OpenStax Psychology (2nd ed.) Textbook

Alcohol-induced sleep disorders typically occur as insomnia type. 

With acute alcohol use, during the intoxication period, there is a reduction in sleep latency, increase in NREM sleep stages 2 and 3, and reduced REM sleep. Following this, there may be increased wakefulness, restless sleep, and vivid, anxiety-filled dreams during the latter period of sleep. During withdrawal, individuals experience extremely disrupted sleep continuity and increased, intense REM with extremely vivid dreams which can be part of alcohol withdrawal delirium.

With habitual alcohol use, these individuals experience sedative effects for the first half of the night and sleep continuity disruption in the second half. Chronic alcohol users may complain of fragmented sleep for months to years as well as experience slow-wave sleep deficits.

Alcohol-Induced Sleep Disorder

Caffeine can produce insomnia depending on the dose and timing (i.e. larger doses later in the day or during the evening). There is an increase in sleep latency, reduction of slow-wave sleep, increased nocturnal awakenings, and reduced sleep duration. 
Those who consume larger doses of caffeine may experience daytime sleepiness and performance impairments related to withdrawal.

Caffeine-Induced Sleep Disorder

Acute cannabis use may shorten sleep latency, enhance slow-wave sleep, and suppress REM sleep. 

With chronic use, tolerance to sleep-inducing and slow-wave sleep enhancing effects develop.

Withdrawal often leads to persisting sleep difficulties and unpleasant, vivid dreams that can last for several weeks.

Cannabis-Induced Sleep Disorder

During short-term use, opioids may leads to increased sleepiness, reduced REM and slow-wave sleep. With continued use, individuals experience tolerance to the sedative effects and experience insomnia symptoms. 

Several PSG studies have shown that opioid use can lead to reduced sleep efficiency, total sleep time, slow-wave sleep, and possibly REM.

Opioid-Induced Sleep Disorder

Effects are similar to opioids. Acute intoxication has been shown to produce an increase in sleepiness, decrease in wakefulness, and sometimes even daytime sleepiness. 

Chronic use can lead to the development of tolerance to these effects, rebound insomnia, and potentially serious withdrawal effects, especially for those with breathing-related issues, such as obstructive sleep apnea and hypoventilation. 

Parasomnias have been associated to higher doses of benzodiazepine receptor agonist medications and other sedative drugs.

Sedative/Hypnotic/Anxiolytic Substances

Stimulant-Induced Sleep Disorder

Chronic tobacco use can lead to symptoms of insomnia, a reduction of slow-wave sleep and sleep efficiency, increased daytime sleepiness, and regular nocturnal awakenings (due to tobacco cravings). Withdrawal can lead to impaired sleep.

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