Gina Johnson
Sleep disturbances are highly prevalent among people with bipolar disorder. Bipolar disorder is a mental illness characterised by alternating periods of elevated and depressed mood. Sleep disturbances can occur during all stages of bipolar disorder and can negatively impact the course of the illness, quality of life, functioning, symptom burden, and treatment outcomes.
During mania or hypomania, sleep disruptions are commonly presented as a reduced need for sleep. During depression, sleep disruptions are commonly exhibited as hypersomnia or excessive sleepiness. Bipolar depression is also often characterised by severe insomnia. Sleep disturbances are also associated with worse course of illness. For example, sleep disturbances were cited as the most common prodrome for a manic episode.
The high rates of sleep disturbance in individuals with bipolar disorder, its pervading presence across the subtypes and stages of this condition, and its deleterious impact on its course, raise an important question: Why does sleep seem to be at the root of bipolar disorder?
| Characteristics | Values |
|---|---|
| Insomnia | Difficulty falling asleep, staying asleep, or getting too little sleep |
| Hypersomnia | Oversleeping |
| Decreased need for sleep | Able to function with little or no sleep |
| Delayed sleep phase syndrome | Circadian-rhythm sleep disorder resulting in insomnia and daytime sleepiness |
| REM sleep abnormalities | Vivid or bizarre dreams |
| Irregular sleep-wake schedules | Lack of a sleep routine |
| Co-occurring drug addictions | Disrupt sleep and intensify pre-existing symptoms |
| Co-occurring sleep apnea | Cause excessive daytime sleepiness and fatigue |
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What You'll Learn
Bipolar disorder and insomnia
Bipolar disorder is a mental health condition previously known as manic depression. It is characterised by periods of extreme mood swings, from emotional highs (mania or hypomania) to depressive lows. Bipolar disorder is often associated with sleep problems, and these can be a core symptom of the condition.
Insomnia and Bipolar Disorder
During a manic episode, a person with bipolar disorder may experience a reduced need for sleep. They may go for days without sleep without feeling tired. However, insomnia is also common during periods of mania or hypomania. Insomnia is the inability to fall asleep or remain asleep long enough to feel rested, resulting in feelings of tiredness the next day. Insomnia can also occur during depressive episodes. Hypersomnia, or oversleeping, is sometimes even more common than insomnia during periods of depression in bipolar disorder.
Impact of Sleep on Bipolar Disorder
Sleep problems can worsen the symptoms of bipolar disorder, and bipolar symptoms can interfere with a person's ability to sleep. Lack of sleep can trigger new bipolar episodes and can be a warning sign that a manic episode is about to occur. Sleep deprivation can also trigger hypomanic or manic periods. Poor sleep can lead to increased moodiness, depression, worry, difficulty concentrating, and a higher risk of accidental death.
Treatment
It is vital for people with bipolar disorder to be mindful and protective of their sleep cycle, even when they are feeling stable and functioning well. Treating insomnia or sleepiness during different mood states can improve quality of life. Strategies for improving sleep include seeking professional help from a mental health professional, adjusting bipolar medications, setting a bedtime schedule, and keeping a sleep diary. Bright light therapy and cognitive behavioural therapy can also help to address sleep problems and improve bipolar symptoms.
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Sleep deprivation and bipolar disorder
During mania or hypomania, sleep disruptions are commonly presented as a reduced need for sleep. During depression, sleep disruptions are commonly exhibited as hypersomnia or excessive sleepiness. However, bipolar depression is also often characterised by severe insomnia. Importantly, this sleep disturbance is associated with a worse course of illness. For example, sleep disturbances were cited as the most common prodrome for a manic episode.
The high rates of sleep disturbance in individuals with bipolar disorder, its pervading presence across the subtypes and stages of this condition, and its deleterious impact on its course raise an important question: Why does sleep seem to be at the root of bipolar disorder?
A widely accepted explanation for sleep disturbances in bipolar disorder rests on a circadian system model, which posits that sleep problems among bipolar patients result from dysregulated circadian rhythms. Circadian rhythms are biological processes that adopt an ~24-hour cycle or rhythm. Such biological processes include internal body temperature regulation, feeding activity, hormone secretion, the sleep-wake rhythm, and overall mood. Rhythms are considered to be circadian if they occur without external cues or if they are endogenous (eg, originate internally). Thus, circadian rhythms are an innate system that allows the body to maintain the processes critical to survival, health, and overall functioning (eg, hormones, sleep, and temperature).
The sleep-wake cycle is importantly regulated not only through a circadian system process (process C) but also through the process of sleep-wake homeostasis (process S). This process ensures that the drive, or need, for sleep progressively increases with continued wakefulness, such that the longer one has been awake, the greater the drive for sleep. The need for sleep is typically at its maximum in the evening (eg, bedtime). The converse also holds true; increased sleep is associated with a decreased need for sleep. Thus, sleep-wake homeostasis is an important process regulating sleep time and duration.
Recent research has determined that a nonadaptive circadian system is a biomarker of bipolar disorder. Specifically, individuals with bipolar disorder have weakly entrained circadian systems, which contribute to their mood episodes and impact their social rhythms such as sleep and meal timing. According to a circadian rhythm disruption model of bipolar disorder, abnormal circadian rhythms interact with various competing social zeitgebers, leading to mania (characterised by behavioural activation) or depression (characterised by behavioural inhibition).
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Sleep and bipolar disorder medication
Sleep disturbances are very common in people with bipolar disorder and appear to play an important role in the cycling of the disorder. Sleep problems can worsen symptoms of bipolar disorder, and bipolar symptoms can interfere with your ability to sleep. Bipolar disorder may affect sleep in many ways, including insomnia, hypersomnia, decreased need for sleep, delayed sleep phase syndrome, REM sleep abnormalities, and irregular sleep-wake schedules. Certain bipolar medications may also affect sleep as a side effect.
To address sleep issues, it is important to be mindful and protective of your sleep cycle, even if you are feeling stable and functioning well without symptoms. This may involve seeking professional help from a mental health professional or a doctor at an accredited sleep disorders center. You may also ask your doctor for sleep-friendly tweaks to your bipolar medications, such as taking medications at specific times of day to minimize their impact on your sleep.
In addition, there are several strategies you can implement to improve your sleep hygiene, including:
- Establishing a consistent sleep and wake schedule
- Optimizing your bedroom environment by keeping it cool, dark, and quiet
- Avoiding alcohol and caffeine before bedtime
- Prioritizing a nutritious diet and regular exercise
- Winding down before bedtime with relaxing activities such as reading or meditation
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Sleep and bipolar disorder treatment
Sleep and bipolar disorder are closely linked, with sleep disturbances being a core symptom of bipolar disorder. Sleep problems can make bipolar disorder more difficult to manage and can trigger new episodes. Bipolar disorder can also cause sleep issues, with insomnia and hypersomnia being common during periods of mania and depression.
If you have bipolar disorder, it is vital to be mindful and protective of your sleep cycle, even if you are feeling stable and functioning well. Here are some strategies to help you get better sleep:
- Seek professional help: Treatment by a mental health professional can improve your bipolar symptoms, including sleep issues. Consider scheduling an appointment with a doctor at an accredited sleep disorders centre.
- Optimise your sleep hygiene: Establish a consistent bedtime and waking time to help maintain your circadian rhythm and improve your chances of a good night's rest. Avoid naps, especially in the late afternoon. Reserve your bedroom for sleep and sex only.
- Adjust your medication: Medications used to treat bipolar disorder may cause sleep issues as a side effect. Ask your doctor if you should take your medications at specific times of day to minimise their impact on your sleep. Sometimes, adjustments to the types or doses of medication can help.
- Avoid stimulants: Avoid caffeine and alcohol late in the day. Stimulating activities, such as watching TV or using your phone, can also disrupt your sleep, so it's best to unplug from electronic devices at least an hour before bed.
- Optimise your bedroom: Keep your bedroom as dark, quiet, and cool as possible. Use fans, heaters, blinds, earplugs, or sleep masks as needed.
- Exercise: While it's important not to exercise too late in the day, regular exercise can help improve your sleep.
- Try relaxation techniques: Techniques such as visualisation and meditation can help you relax and prepare your body for sleep.
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Sleep and bipolar disorder diagnosis
Bipolar disorder is a mental health condition characterised by alternating periods of elevated and depressed mood. Sleep disturbances are a core symptom of bipolar disorder, and they can occur during all stages of the condition. Sleep problems can make this mood disorder more difficult to manage.
How Bipolar Disorder Affects Sleep
Bipolar disorder can affect sleep in several ways:
- Insomnia: The inability to fall asleep or remain asleep long enough to feel rested.
- Hypersomnia: Oversleeping, which is sometimes more common than insomnia during periods of depression.
- Decreased need for sleep: The ability to get by with little or no sleep without feeling tired the next day.
- Delayed sleep phase syndrome: A circadian-rhythm sleep disorder resulting in insomnia and daytime sleepiness.
- REM sleep abnormalities: Which may make dreams very vivid or bizarre.
- Irregular sleep-wake schedules: Which can result from a lifestyle that involves excessive activity at night.
- Co-occurring drug addictions: Which may disrupt sleep and intensify pre-existing symptoms of bipolar disorder.
- Co-occurring sleep apnea: Which may affect up to a third of people with bipolar disorder, causing excessive daytime sleepiness and fatigue.
How Sleep Affects Bipolar Disorder
Poor sleep can worsen symptoms of bipolar disorder, and bipolar symptoms can interfere with your ability to sleep. Sleep deprivation can trigger manic or hypomanic episodes in some people with bipolar disorder. Sleep disturbances are often present before a mood episode and during an acute mood episode. Sleep disturbances can also occur between acute episodes of bipolar disorder.
Sleep as a Treatment for Bipolar Disorder
Sleep deprivation has been found to enhance mood in up to 60% of patients with depression. Sleep deprivation therapy, in combination with other treatments, may be beneficial for some people with bipolar disorder. However, sleep deprivation can also be associated with a subsequent depressive episode relapse.
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Frequently asked questions
Bipolar disorder can affect sleep in many ways. During a manic episode, a person with bipolar disorder may experience a reduced need for sleep. During a depressive episode, they may experience insomnia or hypersomnia. Bipolar disorder can also cause nightmares, delayed sleep phase syndrome, and irregular sleep-wake schedules.
Sleep problems can worsen the symptoms of bipolar disorder, and bipolar symptoms can interfere with your ability to sleep. Sleep deprivation can trigger manic or hypomanic episodes in people with bipolar disorder.
Maintaining good sleep hygiene is critical for people with bipolar disorder. This includes establishing a consistent sleep schedule, optimizing your bedroom for comfort and minimal distractions, avoiding caffeine and alcohol before bed, and exercising earlier in the day.
