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https://www.bphope.com/take-your-sleep-to-the-next-level/
Sleep is essential to the ongoing maintenance of bipolar. From self-documentation, exercise, and limiting stressors to strategies for regulating circadian system, find your best shut-eye solution.
Insomnia & Bipolar
If there were an Olympics for insomnia, Rachael of Ohio might have a shot at the gold. For three excruciating years, she couldn’t sleep longer than two to four hours at a time. And she participated in all three insomniac events: difficulty falling asleep, waking in the night, and waking up too early in the morning.
With a scientist’s dedication, she studied every aspect of her life: When she slept and how well she slept. What and when she ate. How she got along with the people in her life. Which bedtime routines helped her relax and which didn’t.
She also tracked down and consumed current thinking on improving sleep. Based on her diligent research and rigorous documentation, she was able to gradually regulate her sleep pattern.
Rachel now celebrates sleeping an average of seven hours a night.
“This has been a five-year struggle,” the 49-year-old notes. “A lot of things [I do] are preventive, through a lot of experience.”
Like many others with bipolar disorder, Rachael has struggled to get a good night’s rest since her teens. Research shows that the brain and body systems that govern sleep tend to be especially prone to disruption in people with bipolar.
Changes in sleep patterns are a hallmark, and often a harbinger, of mood shifts. There’s the characteristic lack of sleep during hypo/mania, of course, and either not sleeping or oversleeping during depression.
Good Sleep & Bipolar Mood Swings
Getting good sleep stands as one of the primary recommendations for staying in balance. Yet many people with bipolar experience sleep problems on the regular—mood episode or not.
“Inter-episode insomnia is very high,” notes J. Todd Arnedt, PhD, an associate professor of psychiatry and neurology at the University of Michigan. “That’s one of the most common complaints among people with bipolar disorder.”
Arnedt directs Michigan Medicine’s behavioral sleep medicine clinic and co-directs the Sleep and Circadian Research Laboratory in the department of psychiatry. As a clinical psychologist and researcher, he works with individuals who have sleep disturbances and co-occurring bipolar disorder, major depressive disorder, and substance use disorders.
“We have general rules and recommendations for improving sleep, but then you frequently need to modify them to meet the needs of individual patients,” Arnedt says of his practice. “That might look like sleep scheduling strategies. It might look like the addition of melatonin. Reinforcing daytime activities at certain times—we might integrate that.”
Arnedt notes that despite the negative consequences of sleep-gone-haywire, trying to introduce or maintain insomnia interventions in the middle of a mood episode doesn’t always make sense.
“Under some circumstances, you may have to pause the sleep intervention,” he explains. “You have to work carefully with the psychiatrist who is working with that patient and come up with a collaborative plan to stabilize and regulate [the individual’s] mood.”
Catch the sleep disruption early, though, and “oftentimes the reverse happens,” he notes. “You address sleep symptoms and mood improves.”
Sleep Schedules
The field of sleep medicine developed for a reason. According to a 2018 study by sleep specialists at the University of Pennsylvania’s Perelman School of Medicine, one in four American adults experience acute insomnia each year.
Many interventions for insomnia focus on regulating and reinforcing a healthy circadian rhythm. The body clock, as it’s also known, runs a host of internal operations on a roughly 24-hour schedule.
Normally, signals for hunger, alertness, and sleepiness go out at predictable intervals. Physical stress, emotional stress, changes in schedule such as shift work or travel across time zones, and an erratic lifestyle all have a high likelihood of tripping up the system. For some yet-to-be-determined reason, people with bipolar tend to get more easily overset than the general population. Regular, restful sleep becomes a casualty.
Conversely, keeping to a consistent bedtime and wake time, regular meal times, and a fixed exercise schedule all feed back into the body clock and make it stronger.
“A lot of us are living a sort of jetlagged life,” says Allison Harvey, PhD, a professor of psychology at the University of California, Berkeley, and director of the university’s Golden Bear Sleep and Mood Research Clinic.
“It’s as if we’re flying from San Francisco to Hawaii on a weekly basis. Sometimes it can be that profound, the way our bedtimes and wake-up times vary from night to night—from three hours to five hours—and the circadian system just can’t cope with that. It really upsets all of the clocks that our bodies are comprised of.”
Individual Treatment Options
When it comes to insomnia interventions, what helps one person doesn’t necessarily help another. Thus Rachael’s relentless, comprehensive self-documentation.
In her case, she found that sugar and interpersonal conflict pretty much guarantee a restless night. So along with all the usual methods to destress and decompress, she adapted her diet to be sugar-free, alcohol-free, and caffeine-free. She choked off the toxic relationships in her life and learned to touch base with her husband if she starts to think something’s off between them.
Her reading also led her to techniques like taking the hottest shower she can stand so that her core body temperature will drop quickly afterward and trigger sleepiness. (Yes, that’s a thing.) Another discovery: Using a weighted blanket when it feels like her limbs are all abuzz.
It took a lot of time and energy to decipher all the pieces and put solutions into place, she admits: “This is like a job to keep myself stable, that other people don’t even have to think about.”
It’s doubly frustrating when well-meaning but ignorant friends coax her to come out, “just for one night.” While those people can get home late, crash, and recover in a day, she points out, “it can take me days, weeks, months … I sound boring, but there’s really a lot of goodness that comes out of this.”
Carl C. of Philadelphia provides a quite different case study. Yes, he’s made headway against insomnia in the past few years by following recommendations for regulating his circadian rhythm. Keeping up with his prescribed psych meds and staying sober matters, too, he notes.
As for other advice he tends to hear, he’s no fan.
“Some of these things the therapists tell you, it’s almost laughable,” he says. “‘Drink some chamomile tea, read a good book’—that’s not going to work. ‘Try melatonin’ … that ain’t gonna work.”
So what does work for him?
“Exercise. The fresh air. That’s what helps me. With the depression, too.… If I exercise a lot—some days I go for three, four walks—I’m asleep in 5 minutes.”
Long-Term Problems & Smart Solutions
Carl, 54, describes himself as a restless child who would sing to himself at night instead of sleeping. As an adult, he tended to stay up late because he was an on-the-go kind of guy.
Mood symptoms emerged in his 20s, and he received a diagnosis of “bipolar disorder, not otherwise specified” in 1996. (In other words, his frequent hypomanic and rarer depressive shifts don’t meet the full criteria for a diagnosable mood episode.) Decades of self-medicating with alcohol and substance use only worsened his sleep problems.
While Carl dismisses the traditional self-care strategies, he’s shut out from the traditional sleep aids that doctors prescribe. Between his fast metabolism and history of drug use—he’s been firmly on the wagon since 2016—most sleep medications either aren’t effective or might trigger his addiction, he says.
His current combo of psych meds does great at keeping him from spinning too far upward, he adds, “but as far as the sleep, no.”
Sometimes sleep problems can be traced to physical causes in the body, from a wonky circadian system to medical conditions such as acid reflux and chronic pain. Sometimes the problem lies elsewhere: The body gets ready to settle down but the mind continues to race. That’s true during manic episodes, of course, but anxiety—both the acute and everyday kind—also makes falling asleep a no-go zone.
“The concerning effect of psychiatric insomnia is that the individual will eventually crash and may experience a combination of physical, mental, and emotional side effects,” says Markesha Miller, PhD, a licensed psychotherapist in Columbia, South Carolina.
When anxiety and racing thoughts keep Carl up, yoga, meditation, and hot baths don’t cut it. Instead, he does his best to proactively limit stressors before they reach the bedroom, so to speak.
“I try to keep drama-free, chaos-free—keep my life simple, like AA says,” he notes. “Stay in the present, don’t worry about yesterday, don’t worry about tomorrow.”
Sleep Medicine & Sleep Therapy
Sleep medicine mainly focuses on insomnia at the physiological level. Sleep therapy takes more of a body-mind approach.
Carla H. of Indiana, who has bipolar I, has dealt with chronic insomnia since she can remember. About a year ago, she decided to start cognitive behavioral treatment for insomnia (CBTi) with Lisa Medalie, PsyD, a certified behavioral sleep medicine specialist with the University of Chicago Medical Center’s behavioral sleep medicine program.
Going into the program, Carla’s sleep hygiene—a term comprehending the various practices that contribute to getting good sleep on a regular basis—left a lot to be desired.
“I did not know any kind of disciplined pattern,” says Carla. “I would be up at 2 in the morning answering [work] emails.… My husband would yell at me, ‘Stop what you are doing and go to bed.’”
CBTi typically starts with keeping a sleep log. Carla received a worksheet to keep track of sleep-related behavior, starting with certain “pre-sleep” habits: whether she napped during the day, when she took her sleep medications (and at what dosage), what time she shut down all electronic devices, got in bed, turned off the light.
Other categories covered the state of her slumber: how long it took to fall asleep after she closed her eyes, whether she woke in the night, how long it took to fall back asleep, and the overall quality of her night’s rest. After getting a realistic total of actual hours asleep, the therapist can advise on how to consolidate those unconscious periods into a solid block and gradually lengthen the duration.
That’s important because REM sleep—the deepest and most rejuvenating phase of the sleep cycle—occurs roughly every 90 minutes. The longer you stay asleep, the more REM you get.
Carla also got coaching in problem-solving as part of tackling the mental underpinnings of insomnia, such as rumination and the old insomnia classic: lying awake worrying about not sleeping.
Such sleep hacks work best within a larger lifestyle approach. For Carla, that looks like morning meditation, breathing practice, or yoga, acupuncture, EMDR (eye movement desensitization and reprocessing) psychotherapy, and journaling. She powers down her devices well in advance of bedtime (an alert on her phone helps with that) and winds down from the day with undemanding activities.
Carla had developed a dependency on her sleep medications, a not uncommon situation. The insomnia toolbox she’s assembled allowed her to gradually taper off them.
“What I learned from Dr. Medalie has been a game changer,” she says. Her new CBTi skills and lifestyle modifications “made a huge impact on the quality of my life this past year.”
There’s a caveat, though: “This type of discipline for sleep is very difficult for anyone with bipolar. We are easily distracted and entertained, we wanna finish one more episode of the TV series we are binge-watching before going to bed.”
Nonetheless, “I’m making an effort, one day at a time, to change the things I can control.… When I have a good night’s sleep I like myself, my mood, and my life better the next day.”
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