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Insomnia and your Mental Health: Can Lack of Sleep Trigger a Manic or Depressive Episode in Patients with Bipolar Disorder?

Insomnia is defined as a sleep disorder that includes trouble falling asleep, staying asleep, or waking too early, resulting in daytime discomfort or impairment. It is an alarmingly common problem that often occurs along with other medical disorders or acute stress syndromes.  As a result, many clinicians and researchers rightly consider insomnia to be a sign of a deeper underlying condition.

On the other hand, insomnia can also exist in the absence of other medical or mental health issues; under these circumstances, it is referred to as primary insomnia. 

Up to 10% of the population meet strict criteria for insomnia (3 nights of poor sleep per week for 3 months), but many more suffer from subsyndrormal (just short of the diagnostic criteria) leaving nearly 1/2 of all Americans sleep deprived.  although my feeling is that it is much higher. Chronically, it can increase the risk of, and may lead to, a variety of emotional and somatic conditions such as increased mortality and depression.

Insomnia  the inability to fall asleep or to remain sleeping throughout the night, is one of the most common medical complaints seen by health care practitioners. At least 30% of individuals, adults as well as children, experience this common sleep disorder one or more times during their lives. For patients with bipolar disorder, this percentage is much higher - virtually all bipolar sufferers have insomnia to some degree. /_uploaded_files/consequences-of-poor-sleep.png

Not only are sleep disturbances symptomatic of bipolar disorder; many researchers have noted that bouts of insomnia are also triggers of both manic and depressive episodes. Up to 60% of bipolar sufferers report some sort of sleep disturbance directly prior to a manic episode; the inability to get a sufficient amount of rest can result in hormonal and neurotransmitter changes that perpetuate the cycle of mania, depression, and insomnia.

To understand why this happens, it is helpful to understand the basic mechanism of sleep and how it is affected by the abnormalities present in patients with bipolar disorder.

* How Does the Body Regulate Sleep?

The cycle of sleeping and waking (the circadian rhythm) is regulated by the suprachiasmatic nucleus (SCN), the body's internal biological clock. The SCN is activated by daylight detected via the retina; it controls the various hormones and neurotransmitters that oversee the body's cycle of rest and activity:

Melatonin - this hormone is produced in the pineal gland, a small organ located in the brain which is regulated by the SCN. When light is detected during the daylight hours, the SCN inhibits the pineal gland, decreasing melatonin production; when daylight begins to decrease, melatonin levels increase, sending the body the message that it is time to sleep. Bipolar patients regularly exhibit low levels of melatonin.

Serotonin - this neurotransmitter is closely linked with melatonin as part of the sleep-wake cycle. Serotonin levels are high during periods of wakefulness and are converted in the pineal gland to melatonin; when melatonin levels are increased, serotonin levels decrease and are nearly non-existent during REM sleep. Low levels of serotonin are closely associated with bipolar disorder; this affects the synthesis of melatonin, in turn hampering the onset of sleep.

GABA is the primary inhibitory neurotransmitter in the body; its main responsibility is to calm the central nervous system by neutralizing the effects of glutamate, an excitatory neurotransmitter. Low levels of GABA are detected in patients with bipolar and anxiety disorders.

Dopamine - Although levels of dopamine are fairly consistent throughout the sleeping and waking hours, low levels of dopamine correlate to difficulties in falling asleep; individuals with dopamine deficiencies are also prone to frequent waking and prolonged periods of wakefulness. Low dopamine levels are characteristic of patients with bipolar disorder; degenerative neurological illnesses such as Alzheimer's and Parkinson's disease are also associated with insufficient dopamine.

Norepinephrine - this neurotransmitter is associated with a state of alertness, and it is responsible in part for regulating periods of sleep and wakefulness. High levels of norepinephrine are associated with restlessness and insomnia.

Cortisol - this so-called stress hormone is a primary cause of insomnia. People who have difficulty getting to sleep at night invariably exhibit high levels of cortisol - also a characteristic of patients with bipolar disorder.

We all experience stress in our daily lives. Non-bipolar people typically have the ability to cope with their stress; but for bipolar patients, abnormalities in the structure and chemistry of the brain impair their ability to deal with stressful situations. An event as simple as a disruption their daily routine can greatly increase cortisol levels, preventing them from being able to sleep; their insomnia then sets off a manic attack.

A manic episode is characterized by high levels of activity; a manic person may feel extremely energized and feel no need for sleep. This can lead to fatigue on the following day, which results in napping, which in turn prevents the individual from following a normal sleeping pattern at night; this cycle is often self-perpetuating.

Conversely, insomnia can sap the neurotransmitters that regulate mood, thereby triggering an episode of depression. In order to break this pattern of insomnia/mania and insomnia/depression, the insomnia itself needs to be addressed. By identifying the cause of the insomnia and developing a plan for treatment and sleep management, bipolar patients can experience significant relief of their symptoms.

* Causes of Insomnia

As previously discussed, neurotransmitter and hormone imbalances are a significant factor in episodes of insomnia. Other situations which may contribute to insomnia include:

  • Depression/anxiety;
  • Environmental factors such as light, temperature and noise;
  • Medication - certain medications used in treating bipolar disorder, including antidepressants, can interfere with sleep.

By narrowing down the causes of insomnia, it is possible to design a targeted plan for treatment and get back to a regular schedule of sleep.

* Testing for Insomnia Causes

A neurosleep profile is a series of saliva and urine tests which can detect abnormal levels of the neurotransmitters involved with sleep regulation. If neurotransmitter imbalances are detected, dietary supplements for neurotransmitters can help to correct the sleep problem.

* Treating/Managing Insomnia

There are several elements which can address the problem of bipolar-related insomnia and restore a normal sleep routine:

  • Correct neurotransmitter imbalances through supplementing as necessary;
  • Establish (and stick to) a regular bedtime and wake-up time;
  • Maintain a comfortable sleeping environment;
  • Practice a relaxation technique before bedtime;
  • Avoid stress and physical activity before bedtime;
  • Exercise during the daytime hours (this can increase nighttime melatonin levels) - do not exercise within 3 hours of bedtime;
  • Enlist the help of family members, particularly during manic episodes, in adhering to a sleep routine;
  • Avoid caffeine;
  • Avoid smoking and alcohol, which can affect the sleep cycle;
  • Avoid daytime napping.

Bipolar patients should avoid taking sleep aids unless expressly recommended by their doctor; both prescription and over-the-counter sleep medications can cause drug interactions with medications used in treating bipolar disorder. These medications can also cause behavioral and mood changes that may trigger a manic or depressive episode.

With proper attention to good sleep habits, bipolar patients can overcome insomnia and restore a normal sleep routine, greatly reducing the incidence of bipolar symptoms.

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