Continuing Education

Recognizing Thermoregulatory Sleep Dysregulation Disorder: Clinical Patterns, Physiological Mechanisms, and Evidence-Informed Care

From Childhood Through Adulthood

Is This the Patient in Your Practice?

• Fear-driven aggression toward self or others, often triggered by a misperceived threat
• Rapid, pronounced shifts in mood and behavior—sometimes occurring multiple times within a single day—with abrupt changes in irritability, fear, agitation, energy, or emotional control
• Extreme heat intolerance, facial flushing, and night sweats, or the opposite: significant cold tolerance, going outside in near-freezing weather in short sleeves without seeming to notice
• Sleep dysregulation: trouble falling asleep, multiple night arousals, sleep inertia, horrific nightmares, and night terrors
• Sharp deterioration in mood and behavior by late afternoon or evening
• A stack of prior diagnoses (DMDD, ADHD, OCD, autism spectrum) that never quite fit
• Multiple medication trials with little benefit, sometimes with worsening symptoms

Learning Objectives

• Describe the TSDD clinical phenotype across childhood, adolescence, and adulthood, and the relationships among thermoregulation, circadian biology, sleep architecture, REM phenomena, autonomic regulation, and emotional and behavioral dysregulation.
• Explain how an RDoC (Research Domain Criteria) approach anchors the TSDD phenotype in measurable biological mechanisms rather than symptom checklists alone.
• Identify longitudinal patterns of disrupted nighttime sleep, excessive daytime sleepiness, sleep inertia, and REM-related symptoms that warrant further assessment, screening, or referral, at any age.
• Apply structured history-taking and pattern recognition to distinguish hypersomnolence and sleep inertia from psychiatric fatigue, medication effects, and other complex presentations.
• Apply psychological and neuropsychological testing, including the Continuous Performance Test (CPT), to differentiate TSDD from ADHD in clinical assessment.
• Describe the published, evidence-informed treatment paradigm for TSDD, including staged mood stabilization, thermal and circadian intervention, and pharmacologic approaches such as lithium, clonidine, and intranasal ketamine.
• Differentiate established, off-label, nonpharmacologic, and emerging management approaches with attention to evidence, side effects, medication burden, and patient presentation.
• Develop an individualized care plan incorporating patient and family education, shared decision-making, and appropriate interdisciplinary collaboration.
• Implement at least one change in assessment, treatment planning, referral, or patient and family education following the activity.

What You'll Learn

Recognizing the Phenotype

Early parasomnias, co-sleeping, heat intolerance, nighttime overheating, extreme or significant cold tolerance (children who go outside in near-freezing temperatures in short sleeves and don't seem to register it), separation sensitivity, evening worsening, cognitive collapse, and medication activation.

Understanding the Mechanism

Thermoregulation, interoception, circadian phase, distal heat redistribution, REM gating, autonomic load, and physiological margin.

Applying It Clinically

What to ask, what patterns to notice, and how to think about sleep environment, cooling strategies, light timing, school-day load, medication sensitivity, and recovery trajectories.

Differentiating TSDD From ADHD

Psychological and neuropsychological testing that helps separate TSDD from ADHD, including the Continuous Performance Test (CPT), a widely used, objective screening measure participants will learn to apply as a concrete data point in their own diagnostic workup.

Hearing the Family Experience

Direct video narrative from patients and families: the mother describing years of night terrors, the child describing feeling hot before rage, the cumulative toll of years spent misunderstood. Clinicians may debate the underlying hypothesis; they tend to remember the families.

Pharmacologic Principles

Established, off-label, and emerging approaches drawn from the published case-series literature and the 2025 systematic review (including lithium, clonidine, melatonin, and titrated intranasal ketamine) relevant to mood stabilization, state regulation, medication sensitivity, sleep continuity, circadian timing, and thermal-arousal modulation across the lifespan.

Overview

Some children present with fear-driven aggression. Some with nightmares that recur for years, or decades. Some walk outside in thirty-degree weather in short sleeves and don't seem to feel it, while a parent trails behind them with a coat. Some run hot, struggle with sleep dysregulation (trouble getting to sleep, multiple arousals, sleep inertia, nightmares, night terrors, and other parasomnias), and seem to fall apart by late afternoon, a pattern that, left unaddressed, often persists from childhood into adolescence and adulthood. Individually, each symptom fits somewhere in the diagnostic manual. Together, they often don't fit anywhere at all, and the person ends up carrying multiple labels across a lifetime that never quite explain the whole picture.

This course introduces Thermoregulatory Sleep Dysregulation Disorder (TSDD), a clinical phenotype identified and studied over two decades by faculty at the Juvenile Bipolar Research Foundation and recently the subject of a peer-reviewed systematic review in Acta Psychiatrica Scandinavica (Papolos, Teicher, and Post, 2025). The course follows TSDD across the life cycle, from early childhood presentation through adolescence and into adulthood, examining the physiological threads that organize presentations currently fragmented across separate psychiatric diagnoses at every age: thermoregulation, circadian timing, REM sleep stability, and autonomic load.

This course provides clinicians with more than recognition: a structured, evidence-informed approach to what comes after identification, including a staged treatment paradigm (mood stabilization, thermal and circadian intervention, and pharmacologic approaches including intranasal ketamine) that has shown good outcomes across two published case series.

Participants will also learn a structured approach to the sleep and temperature history, a set of questions that's simple to ask but often skipped. Nurse practitioners, primary care clinicians, and mental health providers are frequently the ones best positioned to ask them: they take the detailed history, hear parents describe day-to-day patterns, and track treatment response over time, often before a specialist ever sees the case. The course introduces physiological margin (how much regulatory capacity a person has left after a day of thermal, sensory, and emotional load) as a working construct for assessment and treatment planning at any age.

Faculty combine evidence-informed didactic teaching grounded in the published literature with direct patient and family narrative, structured case-based breakout discussion, and practical tools participants can use the same week. The goal is not to replace existing diagnostic frameworks, but to give clinicians a way of noticing a pattern that current nosology tends to split apart, and a starting point for treating it.

A Severe, Frequently Misdiagnosed Population

Children with TSDD are frequently among the most difficult patients in any psychiatric practice, often carrying a constellation of DSM diagnoses that each capture a piece of the presentation but never quite the whole picture: disruptive mood dysregulation disorder, ADHD, obsessive-compulsive disorder, autism spectrum presentations, among others. Multiple classes of medication are often trialed, frequently in combination, without benefit and sometimes with harm. Across the published case series, stimulants and antidepressants, the most commonly prescribed agents in this population, often worsened the course of illness by increasing cycle frequency or intensifying irritability and aggression, not infrequently resulting in hospitalization.

Left unrecognized, this is not a trajectory that resolves with age. As adolescents, fear-based aggression frequently leads these patients into residential treatment facilities, the juvenile justice system, and repeated psychiatric hospitalizations. As adults, many become among the most treatment-resistant patients in the psychiatric system, still carrying an accumulated stack of diagnoses that never quite fit. This is the population this course is built around, not because the phenotype is rare, but because it is severe, and because it has consistently fallen outside the categories current diagnostic frameworks were built to catch.

This trajectory is also the strongest argument for early intervention. The symptom cluster that defines TSDD can be recognized as early as age six, years before the diagnostic odyssey and escalating levels of care described above take hold. Treated early, the condition does not have to follow that path. Recognizing TSDD in a six-year-old is not just an earlier diagnosis; it's a different outcome.

Grounded in Published Research

TSDD's clinical presentation and treatment paradigm are documented in the peer-reviewed literature. A 2025 systematic review in Acta Psychiatrica Scandinavica (Papolos, Teicher, and Post) examined the pharmacological and psychotherapeutic treatment literature for early-onset specified and unspecified bipolar disorders, finding strong RCT support for family-focused psychotherapy across the broader spectrum, and consistent, positive outcomes across two published case series for the TSDD-specific paradigm: high-dose lithium for mood stabilization, thermal and circadian intervention, and titrated intranasal ketamine for fear- and heat-related symptoms that persist despite mood stabilization.

Controlled trials are the field's clear next step, and this course says so directly. But the pattern itself, and what tends to help, is well documented, well described, and ready to be recognized in practice.

This course presents TSDD through an RDoC lens, the Research Domain Criteria framework the NIMH has identified as the direction psychiatric diagnosis needs to move toward: anchored in identifiable biological mechanisms and measurable dimensions, rather than symptom checklists alone. TSDD's central marker, thermoregulatory dysfunction, is observable, measurable, and heritable, precisely the kind of biological anchor RDoC was built to prioritize.

Developed and Accredited By

Continuing education activities are developed by faculty from the Juvenile Bipolar Research Foundation, Albert Einstein College of Medicine, and Weill Cornell Medicine, and accredited by Albert Einstein College of Medicine–Montefiore Medical Center, Center for Continuing Professional Development (CCPD), a provider that has achieved Joint Accreditation with Commendation.

Who Should Participate

Psychiatric-Mental Health Nurse Practitioners (primary audience), Physicians, Advanced Practice Nurses, Psychologists, Primary Care Providers, Sleep Medicine Clinicians, and Other Clinicians Who Assess or Manage Complex Psychiatric, Sleep, Behavioral, or Circadian Presentations in Patients of Any Age: Children, Adolescents, or Adults.

Tentative Schedule

All times Eastern. Sunday, October 25, 2026.

Eight-Month Supplemental Clinical Case-Review Series

Following the live course, 15 participants will be invited to join an optional eight-month series of monthly 90-minute, non-credit clinical case-review sessions at no additional cost.

Designed with psychiatric-mental health nurse practitioners as its primary audience, this advanced longitudinal series goes beyond symptom recognition to build confidence in assessing, formulating, and treating complex presentations of the TSDD phenotype. Through engaging monthly sessions and real-world case application, participants will explore how sleep-state instability, thermoregulation, autonomic arousal, fear, and mood dysregulation interact, and learn how to translate these connections into more informed, effective clinical decisions.

Faculty

Course faculty bring more than two decades of combined clinical and research experience characterizing this phenotype and its treatment, alongside patient- and family-facing perspective drawn directly from the JBRF community.

Accreditation oversight, disclosure review, content validation, and outcomes measurement provided by CCPD staff and independent professional reviewers.

Hearing From Families

Video is used deliberately throughout this course, not as illustration but as evidence. Participants will hear directly from patients and families at four points in the program: a baseline interview used for pre- and post-course assessment, a case segment used for small-group clinical reasoning, a themed sequence on the cumulative burden of an unrecognized disorder, and closing reflections offering direct guidance from those who live with TSDD to the clinicians who will see the next child like them.

Course Fees

Early Registration Deadline: To Be Announced.

This launch-cohort tuition is made possible through pooled educational grant support and reflects a reduced rate against a full course value of $500–$650. For the 15 participants invited to join the supplemental clinical case-review series, the full eight-month series is included at no additional cost.

Accreditation

In support of improving patient care, Albert Einstein College of Medicine–Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physicians

Albert Einstein College of Medicine–Montefiore Medical Center designates this live virtual activity for a maximum of 6.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation.

Nurse Practitioners and Registered Nurses

Albert Einstein College of Medicine–Montefiore Medical Center designates this live activity for a maximum of 6.0 ANCC contact hours.

To receive credit, learners are required to complete the course evaluation. All evaluations and credit claims must be completed within 60 days of the course end date.

Independence and Integrity

This activity is planned and implemented independently of commercial interests, in accordance with ACCME Standards for Integrity and Independence in Accredited Continuing Education. Commercial supporters have no role in selecting planners, faculty, content, educational methods, learners, or outcomes measures. All financial relationships of planners, faculty, and others in control of content are identified and mitigated prior to the activity.

Disclaimer

This activity is offered solely for educational purposes and does not constitute certification of competency. TSDD is presented using an RDoC-informed, biologically anchored framework rather than as a formal DSM or ICD category; practitioners should consult additional sources of information and exercise their own professional judgment before making clinical decisions of any kind.

Developed by the Juvenile Bipolar Research Foundation. Accredited by Albert Einstein College of Medicine–Montefiore Medical Center, Center for Continuing Professional Development.