Medicine:Sleep in bipolar disorder

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Sleep is known to play an important role in the etiology and maintenance of bipolar disorder.[1] Patients with bipolar disorder often have a less stable and more variable circadian activity.[2] Circadian activity disruption can be apparent even if the person concerned is not currently ill.[3][4]

A decreased need for sleep is a symptom of both a manic episode and a hypomanic episode[5] in bipolar disorder. Sleep disturbances are often a prodrome for the onset of a manic, hypomanic or depressive episode.[6][7] Current research on circadian and sleep-wake processes shows that they play an important role in the etiology and maintenance of bipolar disorder.[8] Previous studies showed that the circadian system can modulate the current mood state with positive affect.[9] When challenged, it can have negative mood consequences.[10]

The social zeitgeber hypothesis therefore proposes that in bipolar disorder the fundamental circadian instability can be moderated by the stabilization of daily rhythms and zeitgeber.[11] According to the hypothesis, a disruption (e.g. life event) could trigger depressive, hypomanic or manic episodes. Inversely, a regular daily rhythm can have a positive effect and lead to a normalization of the circadian system. The goal of treatment programs like the interpersonal and social rhythm therapy is to regulate the social rhythms of a patient and thereby normalize the biological rhythms.[11]

REM sleep in bipolar disorder

Current research on REM sleep found that REM sleep is critical in the processing of episodic emotional memories.[12] When the REM sleep activity in patients with unipolar or bipolar depression were measured, often an increased REM density was found.[13] The increased REM density in unipolar and bipolar depression might have two implications. First, it could represent a failed attempt to depotentiate negative emotional experiences during the sleep.[12] Another possible implication is that the increased REM density may pathologically reinforce negative self-narratives and maintain negative moods after sleeping.[14] Both hypotheses are not yet fully proven but show the importance of sleep and sleep disruptions in bipolar disorder and the need for further research.

Sleep disorders and bipolar disorder

The diagnosis of a bipolar disorder is linked to various sleep disorders.[15] Comorbidities include insomnia and hypersomnia.[16] Other related sleep disturbances are delayed sleep phase syndrome, circadian-rhythm sleep disorder, sleep apnea, REM sleep abnormalities and irregular sleep-wake schedules.[16]

Bipolar disorder is also linked with higher rates of suicidal ideation and suicidal attempts.[17][18] It has been shown that sleep disturbances can have an influence on the suicidality of patients with bipolar disorder.[18] One study found that poor sleep quality and nightmares can increase the risk for suicidal ideation and suicidal attempts.[18]

Genetic vulnerability

Bipolar disorder is known to have a high heritability.[19] Therefore, sleep disturbances in bipolar disorder could also have a genetic basis. Studies found modest associations between several genes that are known to be associated with the generation and regulation of circadian rhythms and bipolar disorder.[20] Two locus interactions between sleep disturbances of the rs11824092 (ARNTL) and rs11932595 (CLOCK) were found in one study.[21]

Sleep disturbances and relapse

Sleep disturbances in bipolar disorder are also an important marker for relapse. Multiple studies found evidence that sleep disturbances contribute to relapse.[20] Sleep disturbances are the most common prodrome of a manic episode and the sixth most common prodrome of a depressive episode.[20]

Sleep disturbance as a residual symptom of a bipolar disorder

Sleep disturbance is not only associated with the onset of manic or hypomanic episodes but also displays a residual symptom of manic and depressive episodes.[20] They are associated with residual depressive symptoms and perceived cognitive performance and can thereby negatively influence the functioning and recovery of a patient.[22] This is one reason why therapy programs such as interpersonal and social rhythm therapy aim to reduce sleep disturbances.[23]

Treatment possibilities regarding the sleep disturbances in bipolar disorder

Interpersonal and social rhythm therapy

A main goal of interpersonal and social rhythm therapy (IPSRT) is to regulate both circadian rhythms and sleep–wake cycles.[23] To achieve this goal, maintaining regular daily rhythms for exercising, eating, sleeping and waking are central to IPSRT. Research has shown that the sleep-wake cycle (circadian rhythms and sleep) can be moderated by social and volitional factors.[9] Based on this chronobiological model, IPSRT aims to manage bipolar symptomatology.[23]

Light therapy for bipolar disorder

A recent study also suggests that bipolar disorder is linked with an enhanced sensitivity to light.[24] In the study, four of the five women who received a midday light session responded well. Three of the four who received light in the morning developed a mixed state, and the others responded well. The authors conclude that light therapy is possibly an effective augmentation strategy in the treatment of bipolar disorder.[24]

Total or partial sleep deprivation

Another proposed treatment for sleep disturbances is total or partial sleep deprivation. Total or partial sleep deprivation has been found to induce an increased mood in depressed bipolar patients.[20] Problematically depressive symptoms often seem to return soon after the patient has slept. Two theories hypothesize, that circadian mechanisms might be the reason.[20]

According to the internal coincidence model, depressed patients are not sleeping at the right biological clock time because the phase angle between the sleep-wake cycle and the biological clock is out of alignment.[25] Based on this theory sleep deprivation works at first because it prevents sleep at the critical phase but in recovery sleep, the misalignment is reinstated.[26]

In the two process model of sleep, it has been proposed, that depression is characterized by a deficiency in the building up of process S.[27] Therefore, sleep deprivation might increase process S in the beginning, but a relapse occurs, when sleep deprivations isn't applied anymore and process S returns to a low level.[27]

References

  1. ↑ Gold, A. K.; Sylvia, L. G. (2016). "The role of sleep in bipolar disorder". Nature and Science of Sleep 8: 207–214. doi:10.2147/NSS.S85754. PMID 27418862. 
  2. ↑ Jackel, Donna (2019-01-04). "The Truth about the Link Between Bipolar and Creativity" (in en-US). https://www.bphope.com/bipolar-mania-creativity/. 
  3. ↑ Jones, Steven Huntley; Hare, Dougal Julian; Evershed, Kate (2005). "Actigraphic assessment of circadian activity and sleep patterns in bipolar disorder" (in en). Bipolar Disorders 7 (2): 176–186. doi:10.1111/j.1399-5618.2005.00187.x. ISSN 1399-5618. PMID 15762859. 
  4. ↑ Harvey, Allison G.; Talbot, Lisa S.; Gershon, Anda (June 2009). "Sleep Disturbance in Bipolar Disorder Across the Lifespan". Clinical Psychology 16 (2): 256–277. doi:10.1111/j.1468-2850.2009.01164.x. ISSN 0969-5893. PMID 22493520. 
  5. ↑ Diagnostic and statistical manual of mental disorders : DSM-5.. American Psychiatric Association., American Psychiatric Association. DSM-5 Task Force. (5th ed.). Arlington, VA: American Psychiatric Association. 2013. ISBN 9780890425541. OCLC 830807378. https://archive.org/details/diagnosticstatis0005unse. 
  6. ↑ Jackson, A.; Cavanagh, J.; Scott, J. (2003). "A systematic review of manic and depressive prodromes". Journal of Affective Disorders 74 (3): 209–17. doi:10.1016/s0165-0327(02)00266-5. PMID 12738039. 
  7. ↑ Sierra, P.; Livianos, L.; Arques, S.; Castelló, J.; Rojo, L. (2007). "Prodromal symptoms to relapse in bipolar disorder". The Australian and New Zealand Journal of Psychiatry 41 (5): 385–91. doi:10.1080/00048670701266854. PMID 17464729. 
  8. ↑ Murray, Greg; Harvey, Allison (2010). "Circadian rhythms and sleep in bipolar disorder" (in en). Bipolar Disorders 12 (5): 459–472. doi:10.1111/j.1399-5618.2010.00843.x. ISSN 1399-5618. PMID 20712747. 
  9. ↑ 9.0 9.1 Murray, Greg; Allen, Nicholas B.; Trinder, John (2002-01-01). "Mood and the Circadian System: Investigation of a Circadian Component in Positive Affect". Chronobiology International 19 (6): 1151–1169. doi:10.1081/CBI-120015956. ISSN 0742-0528. PMID 12511032. 
  10. ↑ Meyrer, Robert; Demling, Joachim; Kornhuber, Johannes; Nowak, Magdalena (2009). "Effects of night shifts in bipolar disorders and extreme morningness" (in en). Bipolar Disorders 11 (8): 897–899. doi:10.1111/j.1399-5618.2009.00767.x. ISSN 1399-5618. PMID 19922558. 
  11. ↑ 11.0 11.1 Grandin, Louisa D.; Alloy, Lauren B.; Abramson, Lyn Y. (2006-10-01). "The social zeitgeber theory, circadian rhythms, and mood disorders: Review and evaluation". Clinical Psychology Review 26 (6): 679–694. doi:10.1016/j.cpr.2006.07.001. ISSN 0272-7358. PMID 16904251. 
  12. ↑ 12.0 12.1 Van Der Helm, E.; Walker, M. P. (2009). "Overnight Therapy? The Role of Sleep in Emotional Brain Processing". Psychological Bulletin 135 (5): 731–748. doi:10.1037/a0016570. PMID 19702380. 
  13. ↑ Krystal, A. D.; Thakur, M.; Roth, T. (2008). "Sleep disturbance in psychiatric disorders: effects on function and quality of life in mood disorders, alcoholism, and schizophrenia.". Annals of Clinical Psychiatry 20 (1): 39–46. doi:10.1080/10401230701844661. PMID 18297585. 
  14. ↑ Walker, Matthew P. (2009). "The Role of Sleep in Cognition and Emotion" (in en). Annals of the New York Academy of Sciences 1156 (1): 168–197. doi:10.1111/j.1749-6632.2009.04416.x. ISSN 1749-6632. PMID 19338508. Bibcode: 2009NYASA1156..168W. 
  15. ↑ "Bipolar Disorder: Sleep Problems and Treatments" (in en). https://www.webmd.com/bipolar-disorder/guide/bipolar-disorder-and-sleep-problems. 
  16. ↑ 16.0 16.1 Kaplan, Katherine A.; Gruber, June; Eidelman, Polina; Talbot, Lisa S.; Harvey, Allison G. (2011-08-01). "Hypersomnia in inter-episode bipolar disorder: Does it have prognostic significance?". Journal of Affective Disorders 132 (3): 438–444. doi:10.1016/j.jad.2011.03.013. ISSN 0165-0327. PMID 21489637. 
  17. ↑ Rihmer, Zoltán; Kiss, Kitty (2002). "Bipolar disorders and suicidal behaviour" (in en). Bipolar Disorders 4 (s1): 21–25. doi:10.1034/j.1399-5618.4.s1.3.x. ISSN 1399-5618. PMID 12479671. 
  18. ↑ 18.0 18.1 18.2 Jamison, Kay Redfield (2000-07-31). "Suicide and Bipolar Disorder" (in English). The Journal of Clinical Psychiatry 61 (suppl 9): 47–51. ISSN 0160-6689. PMID 10826661. https://www.psychiatrist.com/jcp/article/Pages/2000/v61s09/v61s0908.aspx. 
  19. ↑ Cardno, Alastair; Katz, Randy; Sham, Pak; Andrew, Martin; Rijsdijk, Fruhling; McGuffin, Peter (2003-05-01). "The Heritability of Bipolar Affective Disorder and the Genetic Relationship to Unipolar Depression" (in en). Archives of General Psychiatry 60 (5): 497–502. doi:10.1001/archpsyc.60.5.497. ISSN 0003-990X. PMID 12742871. 
  20. ↑ 20.0 20.1 20.2 20.3 20.4 20.5 Harvey, Allison G. (2008-07-01). "Sleep and Circadian Rhythms in Bipolar Disorder: Seeking Synchrony, Harmony, and Regulation". American Journal of Psychiatry 165 (7): 820–829. doi:10.1176/appi.ajp.2008.08010098. ISSN 0002-953X. PMID 18519522. 
  21. ↑ Maciukiewicz, Malgorzata; Dmitrzak-Weglarz, Monika; Pawlak, Joanna; Leszczynska-Rodziewicz, Anna; Zaremba, Dorota; Skibinska, Maria; Hauser, Joanna (2014-07-01). "Analysis of genetic association and epistasis interactions between circadian clock genes and symptom dimensions of bipolar affective disorder". Chronobiology International 31 (6): 770–778. doi:10.3109/07420528.2014.899244. ISSN 0742-0528. PMID 24673294. 
  22. ↑ Samalin, Ludovic; Boyer, Laurent; Murru, Andrea; Pacchiarotti, Isabella; Reinares, María; Bonnin, Caterina Mar; Torrent, Carla; Verdolini, Norma et al. (2017-03-01). "Residual depressive symptoms, sleep disturbance and perceived cognitive impairment as determinants of functioning in patients with bipolar disorder". Journal of Affective Disorders 210: 280–286. doi:10.1016/j.jad.2016.12.054. ISSN 0165-0327. PMID 28068616. 
  23. ↑ 23.0 23.1 23.2 Frank, Ellen; Swartz, Holly A; Kupfer, David J (2000-09-15). "Interpersonal and social rhythm therapy: managing the chaos of bipolar disorder". Biological Psychiatry 48 (6): 593–604. doi:10.1016/S0006-3223(00)00969-0. ISSN 0006-3223. PMID 11018230. 
  24. ↑ 24.0 24.1 Sit, Dorothy; Wisner, Katherine L.; Hanusa, Barbara H.; Stull, Stacy; Terman, Michael (2007). "Light therapy for bipolar disorder: a case series in women" (in en). Bipolar Disorders 9 (8): 918–927. doi:10.1111/j.1399-5618.2007.00451.x. ISSN 1399-5618. PMID 18076544. 
  25. ↑ Wirz-Justice, Anna; Pühringer, Wolfgang; Hole, Günter (October 1976). "Sleep Deprivation and Clomipramine in Endogenous Depression". The Lancet 308 (7991): 912. doi:10.1016/s0140-6736(76)90580-8. ISSN 0140-6736. PMID 62147. 
  26. ↑ Wirz-Justice, Anna; Van den Hoofdakker, Rutger H (1999-08-15). "Sleep deprivation in depression: what do we know, where do we go?". Biological Psychiatry 46 (4): 445–453. doi:10.1016/S0006-3223(99)00125-0. ISSN 0006-3223. PMID 10459393. https://www.sciencedirect.com/science/article/pii/S0006322399001250. 
  27. ↑ 27.0 27.1 Wirz-Justice, A. (2003). "Chronobiology and mood disorders". Dialogues in Clinical Neuroscience 5 (4): 315–325. doi:10.31887/DCNS.2003.5.4/awirzjustice. PMID 22033593. 



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