Bipolar Disorder and Sleep

Bipolar Disorder and Sleep – The Ultimate Guide

Extreme highs, extreme lows, and sleep disorders that go with it are typical for more than 3 million Americans dealing with bipolar disorder.

Unfortunately, poor sleep quality makes it difficult to deal with the symptoms of bipolar disorder, and in some cases, it may cause an episode.

Learning how to sleep better while living with bipolar disorder is key to managing symptoms and reducing their impact on daily life. Keep reading to discover the common sleep problems associated with bipolar disorder, understand the unique relationship between sleep and bipolar disorder, and get tips for sleeping better.

What is bipolar disorder?

Between 1.7% to 4.4% of American adults have bipolar disorder. Also known as manic-depressive illness, bipolar disorder is a brain disorder associated with extreme shifts in mood and energy. What distinguishes these mood shifts from the “normal” ups and downs of everyday life is their severity. The symptoms of bipolar disorder are so extreme and/or regular that they greatly interfere with the life of a person.

While the term “bipolar” has been co-opted by society to describe a random outburst of emotional volatility, that does not accurately characterize the disorder and minimizes what life is like with the disorder. People with bipolar disorder experience mood changes ranging from periods of incredibly high energy to periods that are very low, sad, or even hopeless. These cycles last for days, not just moments.

The symptoms of bipolar have wide-ranging, negative effects on individuals living with it, even when compared to others with ADHD or another mood disorder.

bipolar symptoms quality of life

Symptoms of bipolar disorder

Symptoms of bipolar disorder are categorised into mania and depression. Depressive episodes may directly follow an episode of mania or occur after a neutral state.

Mania symptoms Depression symptoms
Excessive energy and activity levels
Extreme restlessness
Extreme euphoria and optimism, undeterred by negative news or experiences
Racing thoughts or hastened speech
Significantly reduced need for sleep, often resulting in insomnia
Prone to irritability, distraction, or aggression
Worsened, noticeably poor judgement
Increased use or abuse of drugs, substances, or sexual activity
Psychosis
Sense of hopelessness, despair or worthlessness that persists for some time and may lead to suicidal thoughts and/or attempts
Reduced energy and fatigue
Anxious thoughts
Sleep problems, including hypersomnia, insomnia, and early awakenings
Changes in appetite that result in weight gain or loss, or swing between the two
Prone to irritability and restlessness
Impaired focus, memory, and decision-making
Physical pain or digestive problems

When the mania symptoms above last for four days without signs of psychosis, it’s characterized as hypomania. Hypomania is less severe than mania, where symptoms last longer, are more frequent, and show psychotic characteristics that pose a danger to the person or others.

Mixed episodes identify periods when a person experiences both depression and mania symptoms described above. Mixed episodes are followed by a high suicide risk.

Types of bipolar disorder

Depending on the frequency and character of an individual’s symptoms, doctors diagnose bipolar disorder into a few main types:

  • Bipolar I Disorder is diagnosed when a person has experienced at least one episode of mania.
  • Bipolar II Disorder is diagnosed when a person has experienced at least one episode of mania as well as one episode of depression. Usually, depressive episodes are more pronounced and longer than bipolar episodes.
  • Cyclothymic Disorder characterizes people who have more frequent and consistent episodes of depression and hypomania. Typically, their symptoms are less severe than those of bipolar I or II, but the frequency affects their lives to a serious degree.
  • Rapid Cycling describes a period when a person experiences at least four episodes of depression, mania, or hypomania within a year.

The following chart shows the different stages of bipolar disorder:

types of bipolar disorder

Bipolar can be diagnosed in adolescence years or early adulthood, but several individuals rarely seek treatment or diagnosis as symptoms can easily be ignored as “just” impulsive or imprudent; or get confused with similar symptoms from other, separate mood disorders like ADHD. Often, symptoms are masked by other problems like poor academic or career performance (which may in fact be caused by the disorder).

Researchers haven’t yet figured out what causes bipolar disorder. The current theory is that it runs in families. Onset may occur when a person with a genetic predisposition is faced with a traumatic life event.

There is no cure for bipolar disorder, but it can be treated with a mix of psychotherapy, medication, lifestyle changes, and a strong support system of family and friends.

Bipolar disorder and sleep

It makes sense that sleep disorders will be associated with bipolar disorder. Manias are associated with days of unfatigued sleeplessness, excessive activity and substance abuse, which eventually catches up with them and disrupts their sleep. In the other hand, the depressive symptoms associated with bipolar disorder are the same as those diagnosed with psychiatric depression associated with sleep problems.

In reality, for many people with bipolar disorder, sleeping problems may be a warning sign that an episode is coming. Likewise, a period of sleep deprivation or even a jet lag can cause a psychotic episode.

Researchers have charted the interplay between bipolar disorder and sleep:

bipolar disorder and sleep relationship

Common sleep issues associated with bipolar disorder include insomnia, diminished sleeping need, hypersomnia, sleep apnea, delayed sleep phase syndrome, and fatigue.

Insomnia

Insomnia describes difficulty falling or staying asleep. A person with insomnia may take an hour or more to fall asleep. When they eventually fall asleep, the sleep they undergo is of poor quality. They can wake up regularly during the night or wake up earlier than they would have liked. Either way, the next morning, they don’t feel refreshed sufficiently.

Reduced need for sleep

Insomnia is distinct from the reduced need for sleep experienced by 69 to 99% of individuals during a manic episode. Insomniacs feel exhausted and want to sleep, even though it’s out of reach for them.

Conversely, people experiencing a manic episode are so amped up they don’t even feel a need to sleep. Their energy remains undiminished for days, despite not having enough sleep (or at all). This is one of the most common signs of mania.

bipolar manic symptoms

As one bipolar blogger puts it, “People with insomnia count sheep. People with mania draw sheep and make a collage!”

Unfortunately, even if these individuals do not feel exhausted, the effects of sleep deprivation are beginning to take a toll. Even a night of sleep deprivation can increase one’s moodiness and irritability, while impairing their focus, memory, and decision-making skills. Chronic sleep deprivation — like that caused by psychotic spells or cycles of insomnia — makes one ‘s health worse on all fronts: physical, emotional , and mental.

  • The body uses sleep to restore and refresh your body from the stresses of the day. Without sufficient sleep, your body has a tougher time repairing your bones and muscle tissue. As a result, you become more physically tired and are at an increased risk of physical injury or illness.
  • The lack of sleep often weakens our emotional determination, worsens our mood and increases our susceptibility to anxiety or depression.Finally, during REM sleep, your brain process, sorts, and commits to memory all the important things you learned that day. Since the time we spend in REM increases during the latter part of the night, it is essential to sleep a full 7 hours or more in order to experience the benefits. If individuals aren’t sleeping during mania, they’re not getting enough REM, and the research proves it.

Many of the effects of sleep deprivation may sound familiar to you, considering their overlap with the bipolar symptoms listed above. Moodiness, poor judgement, irritability, depression, anxiety, and lack of focus are all symptoms of bipolar disorder. Since these are also caused by sleep deprivation, the detrimental effect is exacerbated only for people with bipolar disorder.

Hypersomnia is normal in people with bipolar disorder during times of depression. In particular, sleep loss has a pronounced negative impact on women with bipolar disorder, significantly increasing their risk for a manic episode.

Hypersomnia

Hypersomnia is the opposite of insomnia. It describes over-sleeping, and it affects one-third of individuals with bipolar disorder. By contrast, it only affects 4 to 6% of the general population.

Hypersomnia is common during periods of depression for anyone with bipolar disorder. However, it is more prevalent among younger individuals and those with bipolar I, while insomnia is more common among those with bipolar II.

People with bipolar disorder tend to experience one of two subtypes of hypersomnia:

  • Long sleep: This describes individuals who sleep 10 or more hours. They also spend much more time in bed generally, whether or not they are asleep. Long sleep may be a warning sign that the episode of depression is nearby.
  • Excessive sleepiness: This describes people who stay in bed for a normal amount of time, but they remain excessively tired during the day, wishing they could get more sleep. This too is often a warning sign, but for mania, rather than depression.

Sleep apnea

Sleep apnea describes a type of sleep-disordered breathing where the person briefly stops breathing during sleep, generally due to blockage or narrowing of their airways, as is often the case with obesity.

Because obesity is linked with insomnia as well as bipolar disorder (particularly due to the weight gain during depression or varied appetite needs between episodes), sleep apnea frequently coexists with bipolar I disorder.

The recommended form of treatment for severe cases of sleep apnea is CPAP therapy, whereby an individual wears a mask connected to a machine that regulates their breathing during sleep and keeps their airways open. Unfortunately, one study of individuals with comorbid sleep apnea and bipolar disorder found that while CPAP improved their apnea symptoms, as expected, it actually triggered symptoms of mania.

Sleep apnea affects as many as a third of individuals with comorbid bipolar disorder. Individuals with bipolar disorder are two to three times more likely to develop sleep apnea than individuals without any mood disorder, according to a large scale 2017 study of over 5,000 individuals.

Delayed sleep phase syndrome

Individuals with extreme forms of bipolar disorder may disrupt their sleep-wake cycles to such an extent that they develop a circadian rhythm disorder like delayed sleep phase syndrome (DSPS).

Delayed sleep phase syndrome describes people who have significantly shifted sleep-wake cycles. They naturally tire much later at night than others, and have difficulty waking up at “normal” times for school and work. In turn, DSPS causes insomnia and daytime fatigue.

Even when not in a manic or depressive stage, research shows that individuals with bipolar I disorder are more likely to have more irregular sleep-wake cycles, as well as wake up later and sleep longer.

Fatigue

Fatigue is a typical occurrence for individuals with bipolar disorder. Extreme changes in attitude and energy are exhausting for the body. Fatigue most sometimes results in depression or insomnia.

Fatigue is especially debilitating because it’s not just a sense of being extremely tired, but also feeling extremely low-energy and without motivation to do much of anything.

How to sleep better with bipolar disorder

Unfortunately, sleep issues and poor sleep quality are one of the most persistent symptoms of bipolar disorder, still rearing their ugly head even when other symptoms aren’t present.

More sadly, the continuation of these sleep issues increases the severity and frequency of symptoms during both manic and depressive periods, particularly in women with bipolar disorder.

Good, regular sleep is essential to living a manageable life with bipolar disorder. Follow these tips to enjoy healthy sleep, avoid causing a manic episode, and help control your bipolar symptoms.

1. Set and follow a regular sleep schedule.

Organize your day and set aside time at night for you to get at least 7 hours of sleep. Go to sleep and wake up at the same time every day.

If you’re excessively tired, allow yourself one short, 30-minute-or-less power nap in the early afternoon. Nap any later, or for any longer, and you’re likely to fall into deep sleep, from which you’ll wake up feeling even groggier than before. A short nap will refresh you for an afternoon boost of energy, without finding it difficult to fall asleep at night.

2. Look into CBT-I.

CBT-I, short for cognitive behavioral therapy for insomnia,, is a type of psychotherapy that helps patients identify and replace negative thoughts and behaviours around sleep and replace them with healthier ones.

CBT-I the recommended treatment for insomnia, and multiple studies have shown it to be helpful for individuals with bipolar disorder, too. They’re more likely to have negative or incorrect thoughts about sleep, and how their behaviors contribute to their sleep, than non-bipolar individuals who enjoy good sleep on a regular basis – and they experience more disturbed sleep as a result.

small 2013 study found that sleep restriction and stimulus control, as delivered as part of CBT-I, improved sleep for bipolar individuals. Another study found that a CBT-I program of stimulus control, sleep hygiene education and cognitive therapy proved effective for resolving or minimizing the sleep problems associated with bipolar disorder.

3. Establish a bedtime routine.

Following the same set of activities in the same order each night, whether it’s brushing your teeth, turning off your electronics, practicing meditation or aromatherapy, helps train your mind to view that 30 to 60 minute routine as preparation for sleep. During a depressive episode, the routine also gives your mind something to focus on instead of your worries and anxiety.

Because individuals with bipolar disorder are more sensitive to stimulation – from bright lights to heated (even if fun) conversations with family or roommates – aim to introduce a sense of calm at least 2 hours before bed, even before your bedtime routine. Engage in relaxing activities, like reading a book or listening to music.

4. Avoid substances that interfere with sleep.

Legal and illegal substances alike disrupt sleep. Caffeine and stimulants like cocaine wake up your mind, keeping you alert and preventing sleep.

Others, like alcohol or marijuana, may help you fall asleep, but they’ll wake you up earlier than expected and disturb the sleep you do get. Avoid all of the above for a calmer mind and more restful sleep.

5. Exercise regularly, but at the right times.

Exercise helps maintain good health, but if it’s done late at night, it can seriously interfere with your ability to fall asleep, especially if you’re living with bipolar disorder. Exercise energizes the body and makes you feel alert, so avoid doing it before bedtime.

However, a regular exercise routine, when undertaken during the early part of the day, can energize the body during the day, counteracting the effects of fatigue, and tire you out by the time bedtime arrives.

6. Journal in a sleep diary.

Writing your racing thoughts down in a journal can help you sort them out during mania, and writing out your worries can help calm you during depression.

Consider keeping a sleep diary, as well. This way you can keep track of when you’re going to bed and waking up, ensuring you stick to the sleep schedule you set.It can also serve as a valuable screening aid for your doctor if you are concerned that you may have a comorbid sleep disorder.

7. Talk to your doctor.

Talking about your doctor, if you’re concerned about your sleep habits, share your sleep diary with them. Let them know how much sleep you get every night, whether it’s disturbed by overnight awakenings or intense dreams, and how long it takes you to sleep on average.

You may also be asked by your doctor whether any of the drugs you are taking for bipolar symptoms cause sleep problems as a side effect, and whether an alternative option may be more acceptable.

For example, melatonin is a natural supplement that allows many to reset their circadian clock. Ask your doctor for the prescribed dose first to ensure that it does not conflict with your other medicine.

8. Use light strategically.

If you’re feeling especially fatigued during depression, or if you developed comorbid delayed sleep phase syndrome, bright light therapy can help reset your circadian rhythms.

Light therapy uses special lightboxes, available for purchase online, that artificially mimic the strength of sunlight. You sit in front of the box in the morning for 30 minutes or so (or have it sit nearby on your desk) to give you an alertness boost in the morning. 15 to 30 minutes of light therapy in the morning proved effective for women experiencing hypersomnia from bipolar disorder.

Be thoughtful about getting natural sunlight, too. The more natural sunlight your brain perceives during the day, the better attuned your sleep-wake cycles will become to the day-night cycle. Exercise outside in the morning, go for a walk on your lunch break, or position your desk near a window.

9. Practice relaxation.

Relaxation gives your mind something to focus on, whether you’re feeling manic or depressed. For manic episodes, it can calm you down into a feeling of tiredness. During depression, it forces the brain to think of something other than your worry.

Try meditation, visualisation, deep breathing or progressive muscle relaxation strategies. You might consider including one or more of these in your bedtime routine!

10. Create a sleep-promoting bedroom environment.

A bedroom that is cool and dark is a bedroom that promotes sleep. Set your bedroom thermostat to somewhere in the mid-60 degrees Fahrenheit. Keep your bedroom as dark as possible at night, using blackout curtains or an eye mask if necessary.

Invest in a comfortable mattress and bedding that supports and relaxes you. Reserve your bedroom for sleep and sex only, and clear it of any clutter. Otherwise, you’re probably giving your manic mind something to be distracted by. Leave your phone and computer outside the room, too.

Additional resources

Research on sleep and bipolar disorder

  • Sleep Disturbance in Bipolar Disorder Across the Lifespan” is a systematic analysis of various research on bipolar disorder and sleep. It discusses the findings regarding the various sleep issues associated with bipolar disorders, how they affect individuals depending on their age, and how better sleep improves symptoms.
  • Sleep and Circadian Rhythms in Bipolar Disorder” explores research literature on the correlation between circadian disturbances and sleep problems associated with bipolar disorder. It also provides a review of the recommended therapies for these sleep issues, such as light therapy and CBT-I.

Education resources and treatment locators from agencies and nonprofits

Blogs, social media, and community resources

  • Many bloggers write about their own experiences living with bipolar disorder. Famous bipolar bloggers include Natasha Tracy from Breaking Bipolar blog, Daniel Bader from Bipolar Village, and Julie Quick from Bipolar Happens!
  • Bipolar Lives is a community-based site that posts diagnostic tools, tips for coping with bipolar disorder through diet and lifestyle changes, and resources for finding treatment.
  • bpHope is the online version of bp Magazine, a magazine dedicated to serving individuals with bipolar disorder.
  • The Mighty shares community-written blogs, storeys, and news about the bipolar disorder world.
  • Individuals with bipolar disorder and their loved ones can connect with peers through online forums such as the Bipolar Disorder Forum on PsychForums.com, the bpHope Forums, and the Bipolar subreddit.

Written by
Emma Sullivan
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