Knitting up “the raveled sleave of care”: Sleep and Bipolar Disorder


I, for one, am a huge fan. I love that feeling of drifting off, right before my consciousness checks out, and I adore that well-rested feeling I have when I first open my eyes after a productively-slept night. [Those nights are becoming fewer and farther between as I age, but that’s just another one of those little amusements that come from slowly leaving behind those days when anyone would call me “young lady”–except for my ancient Uncle Herbie, who calls any woman under 92 a “young lady,” so I can’t really count him–can I? My mother, with another of her pearls, used to say that getting old is lousy–but it’s better than the alternative, and, as always, mother knows best.]

Sleep disregulation is one of the hallmarks of mood disorders, and, if it’s on the side of the inability to sleep, often one of its tortures.

I can recall the days–oh-so-fondly–when sleep came–early and often, like Chicagoans vote. Then, of course, the key was fighting it. Remember those college nights of coffee and No-Doz? I do–and somehow I was always asleep by 3:30 anyway, head on the book on my desk, still holding the M&Ms that were a pre-requisite for any all-nighter.

As appealing as it sounded then to just rev your motor and go, reduced need for sleep is actually bad news. For a person with bipolar disorder, it’s often one of the first signs of impending trouble, as not needing your shut-eye is a hallmark of mania.

And that seems clear enough–you can’t rest, you know you’re speeding up. But what is fascinating is that current research seems to indicate that the reverse is true, as well. That means that simply not sleeping over a period of time can actually help precipitate a manic episode.


In another one of those scientific article titles that I love due to their profoundly uncreative nature, Colombo et al, in the 1999 volume of Psychiatry Research entitled (here we go) “Rate of switch from depression into mania after therapeutic sleep deprivation in bipolar depression” (pretty great, right? You might have some idea of what’s coming now, no?) actually found that a small but significant percentage of bipolar people, when treated to a night of total sleep deprivation, switched into a manic episode.

It’s pretty fascinating.

In an article entitled “Sleep and circadian rhythms in bipolar disorder: Seeking synchrony, harmony, and regulation” in the July 2008 issue of The American Journal of Psychiatry, Allison Harvey studied the impact of disordered mood on sleep–and, interestingly enough, the impact of sleep on disordered mood. Her model suggests that individuals with bipolar have “a bidirectional relationship between daytime affect regulation and nighttime sleep such that an escalating vicious circle of disturbance in affect regulation during the day interferes with nighttime sleep/circadian functioning, and the effects of sleep deprivation contribute to difficulty in affect regulation the following day.”

Great, right? So now what?

Well, here’s where those with bipolar need to be really proactive about taking the sleep matter into their own hands.

As always sleep hygiene [and I love that phrase, it makes me think of those great those fifth-grade hygiene classes, with all the embarrassed 10-year-olds looking anywhere but at the opposite sex–or their friends–but now everyone is slightly drowsy] becomes vital. My guess is that you’ve heard it all before–but now really stick to it. You know–use your bedroom only for sleeping, no napping, get out of bed if you can’t sleep for more than 20 minutes, no TV in bed, make sure you get enough exposure to natural light, shut down the computer 2 hours before sleep–the whole shebang.

And then there are the “when-all-that-fails” ideas:

1. Under your doctor’s careful watch you might try melatonin, which has some research showing it can help sleep during a hypomanic episode.

2. There’s something called “dark therapy” which is cautiously being recommended for those tending toward mania with difficulty sleeping. It exposes the person to complete darkness for an extended period of time, hoping that this will help reset the body’s sleep/wake cycle. [See “Bipolar Disorder, Light, and Darkness: Treatment Implications” for a detailed description.]

3. If your doctor sees it as useful, there are a variety of sedating medications used for difficulty sleeping, especially, in an impending manic phase, benzodiazepines, anti-histamines, and sedating anti-depressants.

4. And there’s a new approach, unique to bipolar patients, called Interpersonal and Social Rhythm Therapy (IPSRT). It’s a therapy that works to help patients maintain regularity in routines–including sleep patterns–and claims to be having some pretty good results, when used in conjunction with psychopharmocology.

The Bard himself recognized that sleep is what “knits up the ravelled sleeve of care,” it is “balm of hurt minds, great nature’s second course, chief nourisher in life’s feast.”

Without it we all start to come unravelled–when the bipolar-disordered person lacks it, she is set on a dangerous course.



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