Tuesday, December 26, 2006

Bipolar Disorder and Sleep

"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.

4 comments:

Anonymous said...

I am a patient with bipolar NOS and sleep disruption has always been a problem for me. I found that no amount of medication/combination of medications were helpful in resolving the issue and, in fact, merely added to the problem with morning grogginess on top of the sleep deprived feeling. Traditional sleep cycle regulation techniques were a complete wash out in my case.

What I did find helpful was meditation and biofeedback training. It hasn't cured the problem, but it has decreased the level of difficulty I experience. I also stopped trying to sleep on the typical schedule as a goal, which decreased the added stress of trying to sleep on a schedule and allowed me to capitalize on my 'natural' sleep pattern.

My comment has more to do with what you say about sleep schedule and its relationship with substance abuse. I read this sort of thing frequently in the literature and it really is one of those kinds of statements that has become an unhelpful and sweeping generalization. I am sure that many of the bipolar disordered do have substance abuse problems as a co-occurring disorder and drug seeking is part of their life patterns while actively abusing. However, these statements assume a causality (drug seeking causes the sleep schedule change) which is not proved conclusively while stigmatizing the symptom by linking it with a drug seeking behavior. It associates a problem experienced by most bipolars who are not substance abusers as relevant primarily in the context of drug seeking behaviors.

Does the substance seeking/attempt to resolve symptoms lead to the scheduling distruption, or is it actually the reverse, where the disruption stimulates or provides opportunity for the drug seeking behavior? I have not heard anyone has proved the case in either direction, yet the conjecture goes unchallenged.

This statement adds in a subtle way to the negative characterizations even within the health care community about bipolar sufferers, linking the symptom and poor schedule regulation inevitably to substance abuse, an activity frought with negative perception.

Aside from this, in my case, I have never had an issue with substance abuse co occurring with my disorder. I have been fortunate. That said, I view the issue of schedule disregulation in terms of shift work and the demands of being in the computer programming industry...where all nighters are not just commonplace, but they are nearly an aspect of cultural identity. Employers expect all nighters 'unofficially', those that do them are rewarded on the job as more productive, and colleagues jibe each other about their stamina in pulling them. In fact, the you cite a study of medical residents...who I imagine have a similar culture with regard to pulling extreme shifts, complete with competitiveness, group right of passage, and other cultural considerations. Consider how differently a patient is perceived by their provider when an occupationally related cause is seen as a factor in exacerbating symptoms. How differntly do we regard the medical residents' lack of perception of their impairment from that of a bipolar sufferer? Do we suggest this potential impairment of judgement where residents are caring for peoples' lives a cause for forcibly treating them for their insomnia? Do we insist they stand down? On the contrary, hospitals are only now coming to grips with the safety issues involved and are reluctant to change their teaching programs to reflect the data you cite.

What a powerful difference is formed in the perception of the CAUSE of the schedule disruption...work versus substance seeking.

The oversimplification of drug seeking behavior as the reason for schedule disregulation in bipolar patients in these articles ignores the other forms of social 'support' for unhealthy sleep habits. It also leads to countless interviews with health providers that focus on substance seeking in relationship to sleep and leave one with an even greater sense of being perceived negatively due to the disorder. And it narrows the thinking of treatment providers, who may be slower to help a patient generate solutions to their sleep disorder that focus on regulating working behaviors or adjusting perceptions regarding one's professional culture.

It still leaves the 'chicken and the egg' question of causality unaddressed, but I agree that the cycle induced with sleep deprivation may well render the causality issue moot and makes breaking the cycle the primary focus for remediation.

For me, the most useful question was not, "Am I sleeping 8 hours at somewhat the same time everyone is expected to?"

I found it more helpful to ask, "How can I obtain enough sleep to feel rested while maintaining my responsibilities?"

Cautiously I might also ask...is it possible that it is less a matter of having a 'short circuit'in my timing for sleep and more a case of being in a minority of individuals who sleep differently?

The more I tried to ape the norm, the worse the result became. As I tried to capitalize on what was more normal for me while being sensitive to the rhythm of conventional life, I found I had more room to make adjustments.

My imperfect answer included several approaches:

recognizing that my alertness cycle simply wasn't timed to the same points in the day as most others

deciding what 'core hours' I needed in my day to be at certain tasks, such as work, caring for my daughter, and personal interests in order for me to be somewhat in 'synch' with coworkers, neighbors, schools, etc.

making an effort to manage my work differently

recognizing that I was more alert and creative for certain art and programming tasks between 1am and 3am but being very sparing about using that time on a recurring basis

and allowing myself to rest as often as possible during the points of the day that yielded refreshing sleep

I tried the conventional sleep hygiene approaches. I tried medication. It was not as helpful. I ended up just as sleep deprived but with extra side effects and grogginess into the bargain. The approach I am trying is more complicated to figure out at the onset and certainly more complicated to maintain as a regular rythym, but it has yielded decent results. My concentration has improved overall, and my sense of fatigue has decreased. (I was not fortunate or unfortunate enough to get the sense of being rested despite a lack of sleep as one of my symptoms.)

In conclusion, I suppose I am asking that providers challenge the assumptions they make and become more alert to the affect these assumptions may make on clinical practice. It is not necessary to ignore basic facts, including the fact that many bipolar sufferers do have cooccurring substance use disorders; but it is, in my view, desirable to avoid making a generalization from that fact that is perjorative and narrows carers perceptions in generating health care strategies with their clients.

As the bipolar diagnosis expands to encompass the bipolar spectrum...and more of us are included in that diagnosis...I think its even more important to decouple unchallenged assumptions from the treatment paradigm.

As a high functioning, but just as sick, bipolar individual I tire quickly of having to explain to my providers and all who come to know of my disorder that I am/have:

employed
a responsible parent
not a drug addict
have never been arrested
a person with a good credit history
educated

and so on. It is tiresome to have to 'educate' each of my providers about my life and yet, still have them somewhat doubtful of my history...assuming I am in denial or concealing something from them.

Setting up these assumptions and perceptions can be a serious barrier to getting the kind of treatment and help that is most likely to be useful.

Ragz said...

Thanks for a nice comment

Risstie said...

Hi , my mom has bipolar. She is getting no sleep, and she cannot function anymore. This has been going on fo a long time, and it breaks my heart to see a terribly thing happen to my mom. She has tried a lot of different suppliments, and they havn't done anythign for her. She also cannot keep spending more and more money, so I need to know if there is somthing out there that can help her, I;m only 13 years old and don't want to lose my mom, so PLEASE , can you tell me a suppliment that would Garantie sleep. PLEASE, I really need help. ='[

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