Saturday, October 07, 2006

Bipolar Disorder and Sleep

Sleep disturbance is a well-recognized feature of acute psychiatric illness, and is included in the diagnostic criteria of many of the affective and anxiety disorders. Recent research has found that disrupted sleep and sleep complaints are common in patients with affective disorder even between mood episodes. Treatment of disrupted sleep and the maintenance of a regular sleep/wake cycle are important components of the prophylaxis of mood episodes in bipolar disorder.
Sleep disturbance is a cardinal feature of bipolar disorder. During acute mania, patients exhibit markedly reduced sleep time and report a reduced need for sleep. Even when euthymic, sleep disturbance is common. In a recent study, 55% of euthymic bipolar patients had chronic insomnia (Harvey et al 2005). Children with bipolar disorder (who often display ultradian rapid cycling rather than distinct mood episodes) exhibit reduced sleep efficiency and frequent nocturnal awakenings (Mehl et al 2006).

Clinical vignette
JW, a single 25 year-old female with bipolar type I disorder, had been relatively stable for the last three years on a regime of lithium 600 mg twice daily and Ambien (zolpidem) 10 mg at bedtime. She had not had a distinct mood episode since her last episode of bipolar mania three years ago. She obtained 7 to 8 hours of sleep at night, and was satisfied with her job as a respiratory therapist working for a durable medical equipment (DME) company.
Four weeks ago, the DME company went out of business, and JW took a job as a sleep technician working for a growing sleep disorders center. This exciting job involved working 8 pm to 6 am Tuesday through Friday. JW was only able to sleep 5-6 hours after her shift, even with the aid of Ambien. She slept about seven hours on nights she was not working.
Three days ago, on a Saturday morning, JW felt unusually energized as she was finishing her shift. She drove home and spent the next sixteen hours cleaning her house from top to bottom. JW then slept for an hour and went to a dance club. She left the dance club when it closed at 3 am and returned to her house, where she slept for two hours. She exercised extensively on Sunday and showed up at the sleep center Sunday night. She told her co-workers she was there because she was now the owner of the sleep center and she wanted to make sure they were doing their jobs right. She was talking rapidly and pacing. JW became agitated when the the other sleep technicians refused to take orders from her. The medical director was called. He, with great difficulty, was able to convince her to go to the ER. The medical director and a technician drove her to the ER, where treatment was begun for a bipolar manic episode.

Comment: JW developed a manic episode with symptoms of grandiosity, decreased need for sleep, rapid speech, and increased goal-directed activity. A change in sleep habits can precipitate a bipolar mood episode. Night work and shift work have a destabilizing influence on bipolar disorder.

Bipolar disorder is treated with mood stabilizing agents such as sodium valproate, carbamazepine, or lithium. Addition of an antidepressant may be necessary to control bipolar depression. The maintenance a stable sleep/wake cycle, as well as regularization of the circadian rhythm, are key components of a relatively new psychotherapy for bipolar disorder, Interpersonal and Social Rhythm Therapy (IP-SRT). IP-SRT is most effective for mood episode prophylaxis in the maintenance phase of bipolar, and in individuals without significant medical comorbidity or anxiety (Frank et al 2005).
The above is from a chapter I am writing for Medlink Neurol0gy entitled "Sleep disorders associated with mental disorders". It is copyrighted by Medlink Neurology.


KWeaver said...

Is it possible that chronic sleep depreviation over several years could cause manic / depressant sympthoms without the patient actually being bipolar?

I think that happened to me, as I was diagnosed with rapid cycling bipolar illness, however the medication never helped, but solving the sleep depreviation did.

However, I will have sympthoms if I go without sleeping for several weeks.

Michael Rack, MD said...

Sleep deprivation can precipitate a bipolar episode in someone with bipolar disorder. Sleep deprivation can cause depressive symptoms in someone without an underlying psychiatric disorder; I suppose it could also cause manic symptoms- for example, a person could be hyperactive and increase their activity level to counteract the sleepiness of sleep deprivation

LBoogieDown said...

I'm a mad woman when I don't get enough sleep. And since I have trouble sleeping I am often "mad."

Really - I turn in to a rapid cycling bi-polarish monster. I recently read a book called Good Night by Michael Breus (great read, by the way) and learned that losing one and a half hours of sleep for just one night reduces daytime alertness by about one-third. For most people, losing sleep impairs memory and the ability to think and process information clearly. For me, when I lose sleep I suffer mood alterations, attention deficits, lethargic reaction times and outright bitchiness. It's pretty bad.

Why is it that I have such severe reaction to lack of sleep whereas others have more mild symptoms?

Mo said...

Like most bipolars, sleep is a good "moodometer" for me, 2 hours when manic, 18 hours when depressed... 6-9 normal.

However, I worked a 3 shift, 24 hour rota for 25 years without any problems. Then I changed job and after a year of working 9-5 I developed severe bipolar illness. So I guess I must be a wierd wierdo.

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Ripley said...

My husband has been diagnosed with Bipolar disorder and Post tramatic stress disorder after a suicidal episode. Add to that he suffers from sleep apnea and works rotating shifts and goes complete unmedicated. Needless to say, he has his moments. I think the information in this article might persuade him to quit his job and find something that will enable him to sleep nights. At least...I really, really, really hope so because at times, I am at a loss with how to cope.

inkbomb said...

I never sleep, it seems. I don't sleep when I'm depressed - and I don't sleep when I'm manic. At least the insomnia doesn't bother me so much when I'm manic - I read, write, mill around the house. When I'm depressed, it's like a strange kind of paralysis. I lie in bed and worry and cannot bring myself to get up and do something. It's such a waste of time. I'm on a cocktail of antidepressant / antipsychotic / mood stabiliser now, which has helped somewhat. But I still don't feel 'well' or 'normal', whatever that may be.

Anonymous said...
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Anonymous said...

I have bipolar type two rapid cycling disorder. I havn't been able to sleep the last two nights or days. So, I was just looking at information online for some thing to do. This makes alot of sense. I had a shift a couple of years ago from 12am to 8am, five days a week. And then some times they would switch me to a day shift here and there. I found out I was bipolar a couple months into this shift. On average I started sleeping an hour and a half every two or three days. FOR THREE MONTHS! My husband thought I was on drugs, which I wasn't. So I ended up going to the doctor.
So yeah, I am going out side. night!

sy said...

Depression only man makes unhealthy. So we try to control it otherwise we may face several problems.

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ron said...

I am bipolar rapid cycler. I have not selpt well for the past 3 months, but I don't have any other manic symthoms, i.e. rapid speech or racing thoughts. I often nap during the day and early evening but find it hard to go to bed at night. When I do I go right to sleep. I take my meds, Depakote and geodon, they make me sleepy. Do you think I am manic?

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skip said...

i'm bipolar 1. i sleep anywhere from 1 1/2 hrs to 4 hrs. lately it's been 1 1/2. this has been an on going problem for me. my pdoc and i have tried trazedone, seroquel, resperidal, lunesta, ambian, abilify (currently), topamax(currently), clonazepan, melatonin, tryptophan, herbs, herb teas...etc. i cruise at a hypomanic level for the most part with an occasional dip in altitude. i know i suffer from short term memory loss from this. skip

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Prevention said...

I am a concerned parent who is seeking information about the impacts of interrupted sleep cycles for kids, particularly kids who are at risk for behavioral health concerns.

I have been diagnosed with bipolar illness since my early twenties. As a child I slept for several years with corrective gear for my teeth. This was extremely painful and interrupted my sleep. I am wondering if there is any connection between long-term sleep interruptions and the development of a behavioral health diagnosis. There is no known history of mental illness in my family.

My daughter who is six has a toe-walking problem. It is now about 75-85% corrected. She is prescribed night braces to help correct her toe-walking. When she wears the braces, she is prone to sleep cycle disturbances including waking up in the middle of the night and nightmares. When she does not wear the braces, she generally sleeps the whole night and needs to be awakened. As a parent I am seeking to do the right thing both for her behavioral health risk as well as her physical health (toe-walking) concerns.

Please share any information you may have regarding interrupted sleep cycles and kids.


Anonymous said...

I currently have had 2 nights of insomnia. I've been diagnosed with and am being treated for bipolar disorder. My meds include Lamictal, Klonopin, Ambien and Lithium. After getting on the right meds, I slept fine until out of the blue I can't fall asleep until about 5 am, and then sleep only a couple of hours before I'm wide awake again. I had run of Lamictal and went without for about 2-3 days, and wonder if this could be the cause. I took my Lamictal yesterday and at bedtime and wonder if sleep will come tonight. I tried Seroquel which knocks me out but after a month, I gained about 10 pounds with no change in diet whatsoever. I quit the Seroquel as a result. I chose to take myself off the Seroquel and haven't told my doctor but hate it!!!! Wonder if there is another sleep aid that can be added to the "witches brew" of chemicals already in my brain?
I don't like messing with my meds and wonde

Gledwood said...

i got severe bipolar symptoms now and have been told off the record i have it and am seeing a shrink monthly who won't give a diagnosis yet... but I'm yet to find a decent medication so i'm off meds and sleeping 2 hours a night then 2.5 hours then maybe 10 hours then 2... and so on problem is for all the stuff you hear about "increased physical energy" mine ain't increaed all the time and when i don't sleep for a few days, i end up spending about half the day really feeling quite sick physically from exhaustion and the other half buzzing, i find exercise makes it more intense, i start hearing voices when i walk up the street but they go if i just sit still. well, as still as i CAN ha ha ha!

and yeah i get hypersomnia in depression up to 17 hours a night every single night; longer if i lose sleep the night before and this is hours asleep, i don't ever lie in bed awake i know some people are meant to do up to 20 hours every single day man that is intense!

i noticed during a time when i wasn't on any definite up or down that my sleep could cycle from 4 hours a night to 14 hours, also i used to get flashes of mania just for a few days without my sleep seeming to go down very much if at all, maybe i went from 9 or 10 hours down to 8 but that's all

now that it's all gone intense the sleep problem has gone equally messed up

but i've had insomnia since my teens, first got depression in childhood and first got bipolar type stuff (mildly) off antidepressants in my early 20s. now i get the manic thing on nothing and antidepressants come nowhere near me the last time on them was such a disaster it was unreal (going up, then crashing badly, still on them and at the prescribed dose, daily i put up with over a month of this till someone said "it's those pills!" and i stopped them; the idiot doctor (a family dr) who prescribed them just would not listen to what i said and implied i should have given them a go for longer. what is it about "hallucinating" that she doesn't understand??!

anyway take care all

ps you know what annoys me the most about this condition? people assuming i'm on drugs when yeah i did have a drug problem and was self medicating but i'm clean now. i might be crazy but not crazy enough to take uppers the state i'm in!!!

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EvieXxxxx said...

I have Bipolar type 1 disorder and I don't sleep what do ever I cry a lot and get angry really easily I feel real bad cause I yell at my boyfriend a lot and he just wants to help me. plus I get sick to the stomach a lot too,I just find I'm stressed and unhappy friends are borning and my boyfriend is annoying I don't want it to be like that I love him so damn much

lal.929 said...
This comment has been removed by the author.
lal.929 said...

The medication, Seroquel, works well for sleep problems associated with bipolar disorder.

lal.929 said...

Recently, I read a good article titled "Lifestyles of People With Bipolar Disorder" on It says that people with bipolar disorder have difficulty in maintaining a daily structured routine. They tend to eat late in the day and sometimes only eat once a day. They also don't maintain regular sleep and wake times. Sound familiar? It was recommended that you try to sleep and wake at the same time every day, even on weekends. Diet and sleep are absolutely crucial in managing bipolar disorder. If you are having trouble sleeping, please talk to your doctor about it, a prescription sleep medicine may be needed. Additionally, it said, you should eat meals and take your medication at the same time every day. Of course, avoid alcohol and non prescribed drugs. I've found that getting a good nights sleep, and eating at regular times (even if your not hungry), drastically improved my mood and anxiety level. For me, taking daily multi-vitamins, especially vitamin D, B-complex, and Omega 3 (fish oil) has also helped.

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