Written by Katie Harris, Content Writer
Bipolar disorder has one of the most complicated relationships with sleep out there. Manifesting during both manic and depressive episodes, and sometimes in between, you might feel like you never get the rest you need. Whether you feel like you’re on the verge of a breakthrough, having the time of your life, or too sad to sleep, missing out on needed rest can have a variety of negative implications with your mental health.
In the worst cases, poor rest can lead to relapses in treatment, and at best, it will likely make it more difficult to manage your condition. Sleep issues are not your fault, and sadly they are extremely common with all types of bipolar disorder.
However, that doesn’t mean rest is unattainable, and with a few expert tips and better understanding, we’re hoping you’ll be able to find what works best for you.
What is Bipolar Disorder?
There are three main types of bipolar disorder, called bipolar I, bipolar II, and cyclothymia. Each is characterized by the widely known and often misconstrued mood swings or seeming changes in personality for weeks at a time. Bipolar I tends to be the most extreme among them, with longer manic and depressive periods, with bipolar II and cyclothymia being less extreme in descending order, though they are not to be confused with milder versions of the same disease.
Confused? Let us explain. While bipolar I disorder might seem more noticeable with higher highs and lower lows, the other two disorders are not mild or less intrusive to those who deal with them every day.
While mood swings are usually required to diagnose the condition, they are different for everyone and vary widely among the different disorders. These highs and lows are caused by hormone shifts in the brain; they could make you feel extremely happy, confident, productive, and social, or extremely depressed, unhappy, sluggish, and low-energy.
These periods of highs and lows don’t always mean one is out of control, but through the use of medicines and hormone treatments, many patients feel much more capable of managing their condition.
These aren’t the only symptoms of bipolar disorder, however. Many people struggle with ADHD or other attention difficulties, anxiety, and sometimes drug abuse. Each of these symptoms and the medication used to treat them might interfere with rest.
Fortunately, through the use of medication and therapy, bipolar disorder can go into remission, pausing the exhausting patterns of highs and lows, and potentially allowing you to live your life in a more stable fashion. Better sleep is key to helping you make it to that point. While it may seem unattainable, many have been able to reach remission, and with the right information, we hope you can do the same.
Common Symptoms:
Highs vs. Lows
Highs
- Fast Driving
- Spending Sprees
- Reckless behavior
These are the signs you might be in the middle of a high, far from the picture of health and happiness some might imagine a bipolar high provides.
Manic phases or “highs” are often caused by extreme stress, poor sleep, or other environmental triggers and sometimes make you feel like you’re on top of the world. In those with bipolar II, these are called hypomanic episodes and generally don’t last quite as long. During these periods you may feel creative, confident, extremely happy, and in some cases euphoric.
While these periods may sound like more fun than the depressive episodes, they’re sometimes accompanied by dangerous or reckless behavior like overspending, driving too fast, or other activities that may put yourself or others at risk. These phases can last for weeks at a time or just a few days, and they can be scary and destructive, sometimes causing financial burdens or legal consequences. Once these phases come to a close, you may be laid up in bed for weeks recovering or diving into a deep low.
Effects on Sleep
These exhaustive episodes can wreak havoc on your rest, making some believe they don’t need to sleep, that they can’t sleep, or that there is simply no time. In other cases, racing thoughts may make it difficult to calm your mind. During these mood episodes, you may experience a psychotic episode where you believe you are someone rich or famous or have special powers, which could make it difficult for you to differentiate between reality and hallucinations.
One Brazil study shows there could be a correlation between a lack of rest and the risk for psychotic episodes among those with bipolar disorder.
Lows
Depressive episodes or “lows” commonly follow and/or precede manic phases or hypomanic phases in those with bipolar I and II. These phases aren’t the same for everyone, and in some cases, they may resemble a normal depressive episode, and in others, it can become more severe. According to the Mayo Clinic, these lows can trigger feelings of worthlessness and guilt, decreased energy, loss of appetite or increase in appetite, and sometimes suicidal feelings or ideation.
Effects on Sleep
According to a study at the Massachusettes General Hospital, up to 78 percent of people with bipolar disorder experience hypersomnia, or excessive sleep during depressive episodes. In some cases, patients didn’t always sleep for longer, sometimes they were just excessively sleepy during the day. It’s also common to experience insomnia during lows, which tends to lead to worse management of the illness, according to the study.
Mixed Bipolar Episodes
According to the National Institute of Mental Health (NIMH), it is possible to experience symptoms of highs and lows at the same time. If this seems like a paradox, think of scaling a greased pole while wearing a faulty jet pack. You might shoot up with a burst of fuel and slide right back down when you temporarily run out of gas.
These episodes tend to be unpredictable and exhausting, making it difficult to manage a schedule and making rest difficult to obtain.
Effects on Sleep
During a mixed episode, you might experience both ends of the sleep spectrum, where you feel less need for sleep until you crash into a low and sleep for longer periods than are typical. This could disrupt your body’s natural sleep cycle and make it difficult for you to get back to “normal” when the episode ends.
Disruption of the
Circadian Rhythm
Rest is at the center of bipolar disorder, directly connected to the patterns of highs and lows. By looking into the circadian rhythm in those with bipolar disorder, we begin to see exactly why that is. According to the Brain & Behavior Research Foundation, significant disruptions in the circadian rhythms among those with BD are correlated with episode triggers, and regulating the rhythm could help significantly with the management of the condition .
Simply put, the circadian rhythm is the internal clock that tells us when to rest, wake up, and often dictates our activity levels. We have circadian cells throughout our entire body, but they are mainly controlled by light receptors in the brain to keep us synced up and running smoothly. When it comes to bipolar and other mood disorders, there are some pretty unsettling correlations between sleep issues and affective disorders.
However, this could be a chicken and egg situation–which came first? The BBR Foundation has conducted extensive research into the relationship between the circadian rhythm and bipolar disorder, and there are a few theories we think you should be aware of.
When it comes to depression, symptoms are most active in the morning, common in the winter, and common in areas with little light, which shows a strong connection to the way the circadian rhythm functions.
In mania, the BBR Foundation shows that changes in schedule and traveling across time zones often predict “highs,” which tend to be more common in the spring or fall. These changes in your sleep patterns are likely to affect your social and waking life, which could put you out of sync with the rest of the world, and could exacerbate your condition and sleep issues, which leads us to another theory about sleep and bipolar disorder.
The Social Zeitgeber theory hypothesizes that affective episodes in bipolar disorder stem from a domino effect beginning with a life event that leads to a change in one’s schedule. From there, it leads to abnormalities in sleep schedule which lead back to social issues and affective episodes. Essentially, in some cases, external triggers could lead to internal triggers, which lead back to affective disorders.
While this theory hasn’t been proven, it offers an explanation of where both external and internal triggers can lead to highs or lows. Coincidentally (or not) many common treatments for bipolar disorder also affect rest. In depressive episodes, some doctors recommend bright light therapy, total sleep deprivation, social rhythm therapy, and in some cases derivatives of melatonin that increase dopamine and norepinephrine, the hormones associated with happiness, sleep, and appropriate stress responses.
Another common treatment for manic phases is lithium, with reduces levels of dopamine when they are too high. While there is ongoing research about how circadian genes regulate dopamine, this is also something the circadian rhythm may regulate when functioning properly.
The BBR Foundation hypothesizes that having a strong and regular circadian rhythm tends to mean less depression, so the better you can maintain a schedule, the better you may feel. Weak cycles are more likely to be correlated with depression, so when you find yourself losing track of sleeping and waking cycles, it could be time to ask for help or make some changes.
At least according to the research, stabilizing the circadian rhythm could be an important measure for treatment and therapy.
Sleeping Too Much
Hypersomnia, or sleeping too much, is common during lows of bipolar disorder. However, recent research from Stanford University shows that there are two subtypes of hypersomnia including long sleep and excessive sleepiness, which may resemble fatigue. Sadly, this period usually feels anything but rejuvenating, and those with hypersomnia are 13.4 percent more likely to engage in substance abuse and more likely to report unhappiness and emotional disturbance.
Long Sleep
Long sleep isn’t necessarily what it sounds like—sleeping for long periods. Instead, you may stay in bed all day, resting intermittently without interruptions of rest at night. These periods are not normal or healthy and may be difficult to overcome, but they don’t always mean you sleep longer than the normal population; you may just stay in bed longer.
Those experiencing long sleep tend to be at a higher risk for future depressive episodes if they experience long sleep between manic and depressive phases, according to research at the University of California, Berkely.
Find Out More: Why Do I Sleep So Much?
Excessive Sleepiness
Excessive sleepiness is different in that these periods could predict future manic episodes, according to the Stanford study. Those with excessive sleepiness tend to sleep an average amount of time (around 7 hours per night) but still experience excessive sleepiness throughout the day, often resembling fatigue.
Insomnia
Insomnia, or trouble falling and staying asleep, is more commonly a characteristic of highs but is also extremely common in the in-between periods where you are generally stable, called Euthymia. In some cases, insomnia could also be related to medications commonly used to treat bipolar disorder.
Research published by the American Journal of Psychiatry shows that euthymic patients with bipolar disorder are more likely to experience nighttime sleep disturbances, impaired sleep efficiency, higher levels of anxiety about sleep, and lower daytime activity levels. It can be extremely frustrating to come to terms with the fact that sleep issues are common at every phase of the disorder, but keep in mind that common is not the same as normal, and there are many options for coping with and managing sleep issues.
As a side note, it’s important to recognize that these symptoms are likely to vary from person to person and between the different categories of bipolar disorder. In other words, just because some people experience insomnia and hyposomnia, doesn’t mean you will. As research has shown that anxiety and fear about sleep can make an issue worse, we’d encourage you to not suffer in advance, and take things one day at a time.
If you are having trouble with insomnia, take a look at our list of best mattresses for insomnia.
Fatigue
Whether it’s the result of sleepless nights, overactive periods of exercise, or strain on your body from stress or medication, fatigue happens, and at times it can feel inevitable and inescapable.
If you’re feeling burned out physically or mentally, it’s important to seek out help, as you may be at an elevated risk for drug abuse or deep depressive episodes. Before it begins to interfere with your health or daily life, you may consider a few treatments for fatigue that have seen some success.
According to Dr. Chris Aiken, Instructor in Clinical Psychiatry at the Wake Forest University School of Medicine, sleep inertia could be partially responsible for increasing fatigue in bipolar disorder. It’s the transition phase between sleeping and waking. When you awake from a deep sleep quickly, this sleep inertia can last from a few minutes to a few hours in depression. It can make you feel groggy, slow your coordination, thought processes, and physical response time.
So even if you get enough sleep, this could be something you’re dealing with. Dr. Aiken recommends two possible solutions in his article for the Psychiatric Times: getting out of bed quickly for physical exercise upon waking, or a dawn simulator to wake you gently so that you are fully awake when you open your eyes. Both treatments should also carry anti-depressant effects, which could be especially helpful in those with bipolar disorder.
Connection to Sleep Apnea
While in some cases a lack of sleep or lasting sleep inertia are the causes for fatigue, there could be other reasons that your sleep feels insufficient. Those with bipolar I may be at an increased risk for developing obstructive sleep apnea, according to research from the University of Pittsburg, especially among those who are overweight.
Sleep apnea is a condition where the body doesn’t breathe properly at night, leading to worsened sleep quality, snoring, and sleep disruptions. In some cases, the condition could be dangerous and requires medical treatment. It comes in a few forms, the two most notable being obstructive sleep apnea (OSA), where there is an actual blockage that obstructs breath, and the other being a neurological condition where the body just stops breathing.
The Pittsburg study addresses the correlation between OSA, depressive episodes, suicidal ideation, and obesity, the last of which could be the link between the two conditions.
In other studies, research shows those with sleep apnea may be at a higher risk for developing a major depressive disorder, so those who have sleep apnea and bipolar disorder may experience more depression than they would otherwise.
Sleep apnea’s relationship with mental health is varied and complicated, but it’s important to note that there is a correlation there, so if you find yourself feeling sluggish and fatigued with no other explanation, it may be something you want to bring up with your doctor.
Learn More: Best Mattress for Sleep Apnea
Poor Sleep Makes Symptoms Worse
You probably don’t need us to tell you that poor sleep in bipolar disorder could make your symptoms worse and in some cases predict a manic or depressive phase. To be fair, poor sleep pretty much makes everything worse. That’s why we aim to help the world get better rest, including you.
We’ve done the research to let you know about the risks that are specific to your condition but encourage you to keep in mind your case is individual. One study in the UK found that sleep deprivation could lead to manic or hypomanic phases in those with bipolar disorder and that these odds increase among women. So if you find yourself consistently struggling to get rest while you’re euthymic, it’s probably a good idea to pull out all the stops and prioritize your rest to avoid an upward or downward swing in your emotions.
Questions for Your Doctor
With an abundance of information on the internet that could easily convince you of a breakthrough medical treatment or, on the other extreme, cause you to lose hope completely, it’s important to include the grounding influence of a licensed medical practitioner in your life. Here are a few questions you may want to ask in your next appointment to get some informed answers about your rest.
Am I sleeping enough? Too much?
Multiple studies show that we as humans are pretty bad at evaluating our sleep efficiency and duration on our own. So rather than panicking or feeling hopeless about our rest, it’s a good idea to check in with your doctor about how your rest measures up. While you definitely shouldn’t dismiss your symptoms of poor rest, you should probably try to refrain from making large conclusions about your health before talking to a doctor.
Insomnia and hypersomnia are both common symptoms of your condition, and your doctor should know how to diagnose them as well as offer some treatment options. Depending on the phase of life you’re in, your sex, and other influencing factors, you may require more or less sleep than is generally recommended, especially during total sleep deprivation treatment. So rather than relying on the web to answer your concerns, it’s a good idea to consult a doctor who knows your case.
Can my medication interfere with my sleep?
This is a great question to ask because your doctor should know which medications you’re taking and may be able to help you draw some conclusions about how they affect each other and your rest. While they may not know right off the bat, this question could lead you to keep track of how you’re feeling over time and help your healthcare team gain some insight into the management of your condition.
In some cases, lithium can decrease the total amount of time spent asleep in depressed patients, and SSRIs may affect REM periods in some patients. While both of these drugs may disrupt your sleep, they radically improve it in others and should be managed on a case by case basis.
Are there natural sleep remedies I could try?
There are a variety of natural products on the market that claim to be able to help you sleep with bipolar disorder, but it’s probably a good idea to run them by your doctor first. While practicing yoga and taking vitamins probably won’t be bad for your overall health, before starting a rigorous new fitness routine or spending lots of money, it’s probably a good idea to ask your doctor their opinion on these methods.
For More Information: Best Natural Sleep Remedies
Can I try melatonin?
Various studies show that melatonin could help treat insomnia in those with BD, but it’s a good idea to discuss any changes in your treatment with a doctor because he or she better understands your medication regimen. If there’s a chance you could be experiencing a circadian rhythm disorder, melatonin could help, or it could throw off your hormones. Your doctor is your best bet in knowing what to expect with your condition.
Melatonin isn’t widely regulated within the United States, so your doctor may also be able to help you determine what dosage to use, when to take it, and which brands could be most effective for you.
Read more about melatonin supplements here.
Managing Your Condition with Better Sleep
The good news is that the cycle works both ways, and studies show that the stronger your sleep habits and the better your rest, the better you should be able to manage your condition. Dr. Erika Saunders of the Penn State College of Medicine says of people with bipolar disorder, “Improving their sleep could not only better their quality of life, but also help them avoid mood episodes.”
In an illness where moderation is key and stability is of paramount importance, sleep is one factor you can’t afford to neglect, no matter how interesting your favorite TV series is getting. With that in mind, here are a few changes you can make to improve your sleep hygiene.
Maintain Sleep Routine
As we learned earlier, the stronger your circadian rhythm, the better you should be able to manage your illness. That means going to bed at the same time each night, waking up at the same time, and trying to get the recommended 7-9 hours of sleep each night. While certain factors may get in the way of you falling asleep, the better you can train your body to rest at specific times, the better chance you have of managing those highs and lows.
If you struggle with routines, you’re not alone. You may consider recruiting your partner, roommate, or child to do a bedtime routine with you, or find a way to be accountable to someone about your sleeping habits.
Try Cognitive Behavioral Therapy
In many cases, CBT can be a drug-free alternative to sleeping pills, which could be especially helpful if you decide with your doctor that adding another medication to the mix isn’t a good idea. CBT is a type of therapy that focuses on identifying behavioral changes like certain thoughts and behaviors that could get in the way of good sleep.
Throughout the program, you may learn to control or eliminate these thoughts and behaviors, leading to better sleep. Though the treatment requires steady practice, in many cases it could be effective in reducing insomnia.
Consider Using Light Therapy
While it’s easy enough to find a lightbox or light alarm on the internet, you’ll want to discuss this treatment with your doctor beforehand to make sure you don’t trigger a manic or hypomanic phase. With bipolar disorder, it’s common to experience shifts in your circadian rhythm, and using light therapy could help you stay in sync when used at the right time.
This therapy is also used fairly often to treat depression in bipolar disorder, which is why you may need to be cautious, especially if you are in a manic phase or especially prone to them. However, with a doctor’s help, it may be just what you need to improve.
For More Information: Best Light Therapy Lamps
Avoid Stimulants
When you’ve been struggling with sleep disruptions and fatigue, caffeine may seem like your only option for getting through a work or school day. Especially because there is a high correlation between ADHD and bipolar disorder, you might even be taking powerful stimulants as a prescription. While these drugs could help you focus during the day, they could be potentially wreaking havoc on your sleep.
If you’ve been prescribed stimulants for your depression, you might want to talk to your doctor if you’ve been having trouble falling or staying asleep, and if you don’t have a prescription, it’s a safe bet to stay away from powerful drugs and limit caffeine use throughout the day.
Consider a Support Group
Unfortunately, bipolar disorder can put you at a higher risk for destructive behaviors such as drug abuse, overspending, and reckless endangerment. If you feel like your sleep is making it more difficult for you to manage your disease, there are support groups available to you online and in-person, which may help you find the support you need.
Conclusion
Bipolar disorder isn’t always a fun time, it requires lots of adjustment and in some cases, it can be exhausting. However you decide to manage your illness, we applaud your effort and hope you find what works for you when it comes to sleep. Your challenges may be unique, but you aren’t alone, and with better understanding and the help of your medical team, we’re sure you’ll be able to find some answers that could help.
Bipolar disorder is a lifelong ordeal, but with better rest, you should be better equipped to manage life’s daily challenges and smooth out the ups and downs.
Katie Harris
Content Writer
About Author
Katie writes content at Sleep Advisor, where she has finally found people who appreciate her true passion for sleep. Based in Austin, Texas, she graduated with a degree in Communications and enjoys combining creativity with research to improve the world’s sleep, starting with her sleepwalking husband.
Combination Sleeper