Bipolar, Your Body Clock and Better Sleep

Are you an night owl or the morning lark? Here’s what you need to know about chronotypes, circadian rhythms, and getting your sleep in sync.

This is a great read from Donna Jackel and BPHope Magazine.

Cass has always been in love with sleep.

“I can easily snooze until 11 a.m. or noon,” says Cass, 28, of Virginia. “I’m always ready for a nap.”

Unfortunately, waking up for school or work has always been a “huge task,” she says. A proverbial night owl, Cass is most alert in the late afternoon and early evening. When left to her own devices, she tends to fall asleep around 2 a.m.

So how does she meet the demands of the real world? With difficulty.

“I have held 9-to-5 jobs and I would be beyond exhausted in the mornings,” says Cass, whose bipolar I was diagnosed at age 19. “I would often take five-hour energy drinks to stay awake, but they made me jittery and my anxiety beyond agitated.”

With a new job as an administrative assistant, Cass has a plan to adapt to business hours. Step 1: Getting to bed no later than 10 p.m. every night—without her cell phone or tablet.

“I used to think [they] helped me fall asleep, but now I know the light can keep you more stimulated,” she says.

When she has trouble falling asleep, Cass listens to a guided meditation or plays calming music.

As for getting to work on time, her partner has promised to wake her every morning.

“It’s feet off the bed, getting up and moving around,” Cass says. “I definitely need a cup of coffee, but I now avoid energy drinks.”

The body’s clock

Night owls like Cass make up one of three broad categories of natural sleep patterns. These chronotypes (from the Greek word for time) appear to be genetically coded, although there are fluctuations according to age.

According to chronobiologist Michael Smolensky, PhD, co-author of The Body Clock Guide to Better Health, around 20 percent of adults can be classed as owls.

A far smaller sliver qualify as larks—up before the sun and positively perky early in the day, but apt to lose steam by evening. Everyone else falls into a more flexible group labeled hummingbirds.

Chronotypes reflect the workings of the body’s internal clock, which is a complex biological system involving skin cells, the gut, and, of course, the brain. These operate together in our daily patterns of waking and sleeping, hunger and thirst, alertness and fatigue—otherwise known as circadian rhythms.

A heap of evidence going back decades connects disruptions in circadian processes to bipolar mood shifts. In 2010, Italian neuroscientist Francesco Benedetti told Scientific American that, “Every time we investigate some [abnormality] of molecular machinery linked to the clock genes, we find an association with bipolar disorder.”

Harry Pantazopoulos, PhD, leads a research team at McLean Hospital’s Translational Neuroscience Laboratory that has been pursuing one clue: People with bipolar show a sharp decrease of a protein called somatostatin in the early morning—contrary to the more typical pattern of increased somatostatin expression at that time of day.

“The decrease of this protein correlates very strongly with the severity of depression and anxiety in the morning,” says Pantazopoulos.

Somatostatin regulates a number of hormones throughout the body, but it also acts in the amygdala, which is the brain’s primitive seat of emotional response. In an initial study published in the journal Biological Psychiatry in May 2016, Pantazopoulos and his colleagues reported that compared to a control group, neurons in the amygdalas of people with bipolar produced less somatostatin.

Interestingly, low mood and fatigue in the mornings, with energy increasing later in the day, is more characteristic of bipolar depression than unipolar depression. So is a tendency to sleep more when depressed, known as hypersomnia.

The opposite happens at the other end of the mood spectrum, of course. Studies suggest that 80 percent of people with bipolar exhibit a decreased need for sleep before the onset of hypomania or mania.

In the genes

Overall, individuals with bipolar tend to have more changes in their sleep patterns in the course of a week than people with no mood disorder. The human circadian system cannot easily tolerate these abrupt shifts, says Pantazopoulos.

An international team of researchers that conducted an extensive study of families with a history of bipolar noted that disturbances in sleep and circadian rhythms “are central features of bipolar disorder, often persisting between episodes.”

The team analyzed sleep-wake and energy patterns of more than 500 members of 26 families over three years. They reported their findings in the February 9, 2016 issue of the Proceedings of the National Academy of Sciences.

On average, those with bipolar I woke later, slept longer, had greater variations in their sleep-wake cycles, and had lower activity levels while awake—irrespective of mood state—than relatives without a diagnosis.

In analyzing genetic variants related to those behaviors, the team identified 13 characteristics that were strongly tied to bipolar I. Such insights into of circadian rhythm processes in bipolar may open the door to better prevention and treatments.

“We know bipolar I is strongly heritable in these families,” says co-author Joseph Takahashi, PhD, who runs a lab at University of Texas Southwestern Medical Center focused on the molecular and genetic bases of circadian rhythms. “If we can find a biological understanding of why this may be happening, we can treat it.”

Timing is everything

Circadian rhythms are directed by a “master timekeeper” called the suprachiasmatic nucleus, which is located just above the optic nerves in the brain and is extremely responsive to light cues.

Anything that messes with the timekeeper can trigger mood symptoms—staying up too late, crossing time zones, Daylight Saving Time (whether “falling back” or “springing forward”), changes in day length as the seasons turn.

Interpersonal and social rhythm therapy, which was developed as a psychotherapy for bipolar, aims to regularize circadian rhythms by emphasizing structure in daily routines, including when you go to bed and when you get up, when you have meals, when you work, even what time you exercise every day.

Your underlying chronotype may complicate the issue, however, especially if your body clock is out of sync with social norms.

People who exhibit “advanced sleep”— wide awake around 4 a.m. but nodding off by 9 p.m.—may do fine with the regular workaday routine. Yet feeling wiped out by early evening can put the kibosh on an active social life and lead to isolation, the American Sleep Association warns.

Phil Steffensmeier of Iowa City, Iowa, actually finds that 5 a.m. is the lonely hour. That’s when he regularly greets the day, but he’s learned not to send any emails before other folks are stirring.

“People get suspicious—they wonder where I’m at in my bipolar cycle, whether I slept at all,” says Steffensmeier, 35.

“Going back to sleep has never been an option,” he adds. “I’ve tried deep breathing and progressive body relaxation and it doesn’t calm my heart rate.”

Those techniques don’t work reliably at bedtime, either, which can vary from 9 p.m. to midnight. Explains Steffensmeier, “The more wired I am, the harder it is to go to sleep.”

If necessary, Steffensmeier takes something to help him sleep, though that may leave him feeling groggy in the morning.

Statistics from the American Sleep Association suggest that about 15 percent of adolescents and adults have difficulties due to “delayed sleep”—meaning they lag far behind customary habits. (For example, they’re more likely to be up in time for lunch rather than breakfast.)

According to psychiatrist and sleep expert Atul Khullar, MD, “delayed sleep disorder is fairly common in people with bipolar disorder.” However, he points out that certain medications have a sedating effect that may contribute to oversleeping in the morning.

One solution would be to ask your prescribing physician if taking your meds at a different time of day would help. You might also discuss the possibility of switching prescriptions to find something that doesn’t affect your sleep as much.

“There are more less-sedating options for bipolar treatment now than there were 10 years ago,” says Khullar, medical director of the Northern Alberta Sleep Clinic and a clinical professor of psychiatry at the University of Alberta.

If you have trouble waking up refreshed and ready for the morning’s activities, it’s also important to consider whether underlying medical conditions may be at work. For example, Khullar suggests being tested for sleep apnea, a sleep disorder in which breathing repeatedly stops and starts.

“It can mimic depression and fatigue and exacerbate feelings of tiredness,” he says.

Rhythm method

For Wendy of San Diego, 44, a stretch of bipolar depression in her 30s led to sleeping 12 to 14 hours a day.

“Typically, I’d go to bed at 8 [p.m.] and wake up at 8 or 10 a.m.,” recalls McNeill, who until then was more familiar with the hyped-up energy of mania. “It was difficult because I had a job as a writing tutor at a community college and I had to be there at 10 a.m.

“There were days when I just couldn’t get out of bed. I used to call in sick a lot.”

Wendy turned to a sleep specialist for help. One of the first things the doctor asked her was whether she exercised.

“She was aghast I did no exercise,” Wendy recalls. “I like to dance, so I started doing aerobics on my own to fast-paced music that I love. I stopped having so much fatigue.”

Wendy gives her exercise program a lot of credit for returning her sleep to a more normal mode, but she made other important changes as well. She no longer smokes or drinks alcohol. And she began seeing a new psychiatrist, who adjusted her medications.

She gets to bed every night at 9 p.m. and rises at 6 a.m. Once in bed, she dims the lights and reads a calming book. At 7 every morning, she meets an 89-year-old friend to go walking. That helps her get up, because she doesn’t want to let him down. Then she goes to work.

“Routine is so important for me,” she says. “It’s all about keeping a steady rhythm in my day.

“I’m like the most boring person alive now,” she jokes. “I try not to mess with my body clock because it will mess up my whole life.”

Notes for night owls
Jack Register, a clinical social worker and executive director of NAMI North Carolina, offers these tips from his professional and personal experience:

FACT-FINDING MISSION: Start with a sleep journal, he advises. “Rate what your sleep is like. What you did before you got in bed. Did you wake up during the night? When you woke up in the morning, did you feel rested?”

At a sleep clinic, specialists might ask you to chart not only your sleep patterns, but also your emotions and attitudes toward sleep. They typically look at your daily routine, too. For example, how much caffeine do you drink and how late? Do you bring your cell phone or tablet to bed? Do you exercise regularly?

SCHEDULE FOR SUCCESS. Try to cluster tasks at your most alert part of the day. For example, Register recommends that college students take their most challenging courses in the late morning or afternoon. “Don’t [plan] things for 8 a.m. if you won’t be able to function,” says Register.

In most cases, employees (and students) can seek accommodations and schedule changes with proper documentation from a psychiatrist or other health care provider. Other possibilities for night owls include working a late shift or finding a job where you can shape your own hours.

SHARE THE NEWS: Make sure your loved ones understand that you oversleep due to a medical condition, Register says. “My mom had bipolar disorder and she never got up with us kids,” he explains. “It wasn’t until years later that we realized that it wasn’t that she didn’t care about us, it was that she had a mental health condition. Understanding the nature of her illness changed the course of our relationship.”

How to build a better bedtime
With patience and discipline, it’s possible to adjust your sleep schedule to meet the demands of the workaday world. Some advice from sleep experts:

• It’s extremely important to wake up and go to bed at the same time, even on the weekend. If you’re naturally a night owl, try moving your bedtime forward gradually—20 to 30 minutes per week.
• Starting winding down 30 to 60 minutes before bedtime. Dim the lights, listen to relaxing music, take a bath, meditate—find whatever works for you.
• Keep your bedroom as dark as possible and as cool as possible without being uncomfortable—between 65 and 70 degrees Fahrenheit (18.5 to 21 degrees Celsius).
• Leave your phone, tablet and laptop outside the bedroom. If you have to get on the computer near bedtime, filter out the screen’s blue light (which interferes with the “sleep hormone” melatonin) by wearing orange-tinted glasses or even regular sunglasses.
• If you’re having difficulty falling asleep, don’t watch the clock—that will only make you anxious. Instead, get out of bed and do something physically and mentally unstimulating, like reading a boring book.
• When it’s time to get up in the morning, don’t hit the snooze button. Open the curtains, make the bed, go outside, talk to a friend. Morning light helps set the body’s internal clock.
• If you’re tired during the day, it’s OK to nap as long as you keep it brief and early in the day. Long naps can throw off your night’s sleep.
• Recognize your triggers. If you know that exercising at night leaves you buzzing, exercise in the morning instead.
• Be aware that alcohol and certain drugs can interfere with sleep.

Leave a Comment

This site uses Akismet to reduce spam. Learn how your comment data is processed.