"How many hours do you sleep on
average at night, and what is the quality of your sleep?" are
two of the first questions I ask every patient on the initial
interview and all subsequent follow-up visits. While the
hypomanic usually gloats over how little sleep he needs, getting
by on 3 to 4 hours a night, the lack of quality sleep can wreak
havoc on his mood and decision-making abilities. Sleep
deprivation results in feelings of malaise, poor concentration,
and moodiness, and even accidental deaths.
In a revealing sleep study published in the September 2005 issue
of the Journal of the American Medical Association, Judith
Owens, MD, and her team of researchers from Hasbro Children's
Hospital in Providence, Rhode Island, followed 34 pediatric
residents from Brown University over the course of 2 years to
compare post-call performance to performance after drinking
alcohol. During this time, the residents were tested under light
call (1 month of daytime duty with no overnight shift, or about
44 hours of work per week) and heavy call (overnight duty every
fourth night with an average of 90 hours of work a week). The
residents performed computer tasks to gauge their attention and
judgment after their light call (after consuming alcohol) and
heavy call shifts (with placebo). The residents who were on
heavy call and had not ingested alcohol performed worse on the
computer tests than those doctors who had taken alcohol and were
on light call. Dr. Owens concluded that the residents were so
sleep-deprived that they didn't recognize that their own
judgment was impaired.
Drugs, stressful situations, and even excessive noise can affect
daily body rhythms and moods. Once a Bipolar II mood disorder
with disturbed rhythms has begun, it tends to be
self-perpetuating, since depression and anxiety are likely to
disrupt 24-hour rhythms further. An irregular living schedule
can aggravate mood disorders. The old-fashioned sanitarium rest
cure was effective with the "nervous" because it put the patient
on a regular schedule of sleep, activity, and meals.
Insomnia
How is your sleep? Do you have difficulty falling asleep? Or do
you toss and turn most of the night until you fall into a deep
sleep just hours before the alarm goes off? A person suffering
from insomnia has difficulty initiating or maintaining normal
sleep, which can result in non-restorative sleep and impairment
of daytime functioning. Insomnia includes sleeping too little,
difficulty falling asleep, awakening frequently during the
night, or waking up early and being unable to get back to sleep.
It is characteristic of many mental and physical disorders.
Those with depression, for example, may experience overwhelming
feelings of sadness, hopelessness, worthlessness, or guilt, all
of which can interrupt sleep. Hypomanics, on the other hand, can
be so aroused that getting quality sleep is virtually impossible
without medication. In a study at the University of Oxford in
the United Kingdom, Allison G. Harvey, PhD, and colleagues in
the department of experimental psychology determined that even
between acute episodes of bipolar disorder, sleep problems were
still documented in 70 percent of those who were experiencing a
normal (euthymic) mood at the time. These normal-mood patients
with bipolar disorder expressed dysfunctional beliefs and
behaviors regarding sleep that were similar to those suffering
from insomnia, such as high levels of anxiety, fear about poor
sleep, low daytime activity level, and a tendency to misperceive
sleep. Dr. Harvey concluded that even when the bipolar patients
were not in a depressive, hypomanic, or manic mood state, they
still had difficulty maintaining good sleep.
Delayed Sleep Phase Syndrome
This is the most common circadian-rhythm sleep disorder that
results in insomnia and daytime sleepiness, or somnolence. A
short circuit between a person's biological clock and the
24-hour day causes this sleep disorder. It is commonly found in
those with mild or major depression. In addition, certain
medications used to treat bipolar disorder may disrupt the
sleep-wake cycle. I often recommend chronotherapy to patients.
This therapy -- an attempt to move bedtime and rising time later
and later each day until both times reach the desired goal -- is
often used to adjust delayed sleep phase syndrome. To adjust the
delayed sleep phase problem, sleep specialists might also use
bright light therapy or the natural hormone melatonin,
particularly in depressed patients.
REM Sleep Abnormalities
REM sleep abnormalities have been implicated by doctors in a
variety of psychiatric disorders, including depression,
posttraumatic stress disorder, some forms of schizophrenia, and
other disorders in which psychosis occurs. Special tests, called
sleep electroencephalograms, record the electrical activity of
the brain and the quality of sleep. From these tests, we know
that in people who are depressed, NREM sleep is reduced and REM
sleep is increased. Most antidepressant medications suppress REM
sleep, leading some researchers to believe that REM sleep
deprivation relates to an improvement in depressive symptoms.
Yet Wellbutrin XL, a common antidepressant, and some older
medications used to treat depression do not suppress REM sleep.
Researchers are therefore still trying to determine the
connection between the REM sleep mechanism and depression.
Irregular Sleep-Wake Schedule
This sleep disorder is yet another problem that many with
Bipolar II experience and in large part results from a lack of
lifestyle scheduling. The reverse sleep-wake cycle is usually
experienced by bipolar drug abusers and/or alcoholics who stay
awake all night searching for similar addicts and engaging in
drug-seeking behavior, which results in sleeping the next day.
This sleep disruption and irregularity make it much more
difficult for the bipolar patient's physician to treat him or
her with conventional medications and adjunctive cognitive
therapy. In most cases, the patient needs to acknowledge the
drug-seeking behavior and get involved in a recovery program
such as Alcoholics Anonymous, Cocaine Anonymous, or other group.
Talk therapy with a psychologist is beneficial to many patients
as they seek to change destructive lifestyle habits and learn
new behaviors that will help them adhere to a more normal
sleep-wake schedule.
Reprinted from: Bipolar II:
Enhance Your Highs, Boost Your Creativity, and Escape the Cycles
of Recurrent Depression -- The Essential Guide to Recognize and
Treat the Mood Swings of This Increasingly Common Disorder by
Ronald R. Fieve, M.D. © 2006 Ronald R. Fieve, M.D. Permission
granted by Rodale, Inc., Emmaus, PA 18098. Available wherever
books are sold or directly from the publisher by calling at
(800) 848-4735
