Bipolar disorder and sleep
LAST UPDATED ON APRIL 11, 2018
Author: AMELIA WILLSON
Extreme highs, extreme lows, and the sleep problems that go with it are commonplace for the over 3 million Americans living with bipolar disorder.
Unfortunately, poor quality sleep just makes it harder to cope with the symptoms of bipolar disorder, and in some cases can trigger 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 severe and/or frequent that they seriously interfere with a person’s life.
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 who have bipolar disorder experience shifts in mood ranging from periods of extremely high energy to periods that are very low, sad, or even hopeless. These periods last for days, not just mere 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.
Symptoms of bipolar disorder
Symptoms of bipolar disorder are split into mania and depression. Depressive episodes may directly follow an episode of mania or occur after a neutral state.
Excessive energy and activity levels
Sense of hopelessness, despair or worthlessness that persists for some time and may lead to suicidal thoughts and/or attempts
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 intense, and present psychotic features that pose dangerous to the individual themselves or others.
Mixed episodes describe times when a person experiences symptoms from both the depression and mania lists above. Mixed episodes are accompanied 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. Typically, the depressive episodes are more pronounced and longer than with bipolar I.
Cyclothymic Disorder characterizes people who have more frequent and consistent episodes of depression and hypomania. Their symptoms are typically less severe than individuals with bipolar I or II, but the frequency interferes with their life to a serious extent.
Rapid Cycling describes a period when a person experiences at least four episodes of depression, mania, or hypomania within a year.
The following chart illustrates the various stages of bipolar disorder:
Bipolar may be diagnosed in adolescence or early adulthood, although many individuals never seek out treatment or diagnosis because the symptoms can easily be dismissed as “just” impulsivity or recklessness, 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 still do not know 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 is treatable 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 problems would accompany 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. On the other hand, the depressive symptoms associated with bipolar disorder are the same experienced by those diagnosed with clinical depression, which is associated with sleep issues of is own.
In fact, for many people with bipolar disorder, the emergence of sleep issues can be a warning sign that an episode is coming on. Likewise, a period of sleep deprivation or even a bout of jet lag can trigger a manic episode.
Researchers have charted the interplay between bipolar disorder and sleep:
Common sleep problems associated with bipolar disorder include insomnia, reduced need for sleep, hypersomnia, sleep apnea, delayed sleep phase syndrome, and fatigue.
Insomnia describes difficulty falling or staying asleep. A person with insomnia may take an hour or more to fall asleep. Once they finally do fall asleep, the sleep they experience is low-quality. They may wake frequently during the night or wake up earlier than they’d like. Either way, they don’t feel adequately refreshed the following morning.
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 tired and want to sleep, although it’s out of reach for them to achieve.
Conversely, people experiencing a manic episode are so amped up they don’t even feel a need to sleep. Their energy remains unabated for days, despite not getting sufficient levels of sleep (or any at all). It’s one of the most common symptoms of mania.
As one bipolar blogger puts it, “People with insomnia count sheep. People with mania draw sheep and make a collage!”
Unfortunately, even though these individuals do not “feel” tired, the effects of sleep deprivation start taking 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 the kind caused by manic episodes or periods of insomnia – worsens one’s health across 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 feel more physically exhausted and are at increased risk for physical injury or illness.
Lack of sleep also weakens our emotional resolve, worsening our mood and increasing our tendency for 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 negative impact is only compounded for individuals with bipolar disorder.
Much research has linked sleep deprivation with a relapse of bipolar symptoms. In particular, sleep loss has a pronounced negative impact on women with bipolar disorder, significantly increasing their risk for a manic episode.
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 can be a warning sign that a depression episode is near.
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 describes a form of sleep-disordered breathing where the individual momentarily stops breathing during sleep, typically due to a blockage or narrowing of their airways, as often happens 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 is a common experience for individuals with bipolar disorder. The extreme shifts in mood and energy are exhausting on the body. Fatigue also often results 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.
Even more unfortunately, the continuation of these sleep problems increases the severity and frequency of symptoms during both manic and depressive episodes, especially for women with bipolar disorder.
Good, regular sleep is essential to living a manageable life with bipolar disorder. Follow these tips to enjoy quality sleep, avoid triggering a manic episode, and better manage 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 quick nap will refresh you for an afternoon energy boost, without making it challenging to fall asleep at night.
2. Look into CBT-I.
CBT-I, short for cognitive behavioral therapy for insomnia, is a form of psychotherapy that helps patients recognize the negative thoughts and behaviors they have 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.
A 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 helpful diagnostic tool for your doctor if you’re worried you’re developing a comorbid sleep disorder.
7. Talk to your doctor.
Speaking of your doctor, if you’re worried about your sleep patterns, share your sleep diary with them. Let them know how much sleep you’re getting each night, whether it’s interrupted by nighttime awakenings or vivid nightmares, and how long it takes you to fall asleep on average.
You might also ask your doctor whether any of the medications you’re taking for bipolar symptoms cause sleep problems as a side effect, and whether an alternative option may be more suitable.
For example, melatonin is a natural supplement that helps many reset their circadian clock. Ask your doctor for a recommended dosage first to ensure it won’t interfere with your other medication.
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 your brain to think about something other than your worries.
Try practicing meditation, visualization, deep breathing exercises or progressive muscle relaxation techniques. 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 just giving your manic mind something to distract itself with. Leave your phone and computer outside the room, too.
Research on sleep and bipolar disorder
“Sleep Disturbance in Bipolar Disorder Across the Lifespan” is a comprehensive review of multiple studies about 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” reviews the research literature focusing on the link between circadian disruptions and the 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
The National Institute of Mental Health provides a helpful overview of symptoms, risk factors, and treatment options for bipolar disorder. Patients can sign up to participate in clinical trials, read the latest research, and find treatment facilities and therapy providers.
Mental Health America shares educational materials about bipolar disorder, links to information to related disorders, and hosts a local directory of treatment resources and support groups.
The Juvenile Bipolar Research Foundation is a non-profit organization that funds research specifically focused on finding treatments for bipolar disorder in children. The site provides helpful information for parents seeking a diagnosis for their children, and reports on the latest research.
The Depression and Bipolar Support Alliance (DBSA) is an advocacy group that shares educational information, advice for coping with bipolar disorder, and access to online and local support groups.