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We
are pleased to present the following
excerpt from the book
Bipolar II: Enhance
Your Highs, Boost Your Creativity, and
Escape the Cycles of Recurrent Depression
-- The Essential Guide to Recognize and
Treat the Mood Swings of This Increasingly
Common Disorder
by Ronald R. Fieve, M.D.
Rodale Books - October
2006
Bipolar
Disorder and Sleep
"How many hours do you sleep on average
at night, and what is the quality of your
sleep?" are two of the first questions I
ask every patient on the initial interview
and all subsequent follow-up visits. While
the hypomanic usually gloats over how
little sleep he needs, getting by on 3 to
4 hours a night, the lack of quality sleep
can wreak havoc on his mood and
decision-making abilities. Sleep
deprivation results in feelings of
malaise, poor concentration, and
moodiness, and even accidental deaths.
In a revealing sleep study published in
the September 2005 issue of the Journal of
the American Medical Association, Judith
Owens, MD, and her team of researchers
from Hasbro Children's Hospital in
Providence, Rhode Island, followed 34
pediatric residents from Brown University
over the course of 2 years to compare
post-call performance to performance after
drinking alcohol. During this time, the
residents were tested under light call (1
month of daytime duty with no overnight
shift, or about 44 hours of work per week)
and heavy call (overnight duty every
fourth night with an average of 90 hours
of work a week). The residents performed
computer tasks to gauge their attention
and judgment after their light call (after
consuming alcohol) and heavy call shifts
(with placebo). The residents who were on
heavy call and had not ingested alcohol
performed worse on the computer tests than
those doctors who had taken alcohol and
were on light call. Dr. Owens concluded
that the residents were so sleep-deprived
that they didn't recognize that their own
judgment was impaired.
Drugs, stressful situations, and even
excessive noise can affect daily body
rhythms and moods. Once a Bipolar II mood
disorder with disturbed rhythms has begun,
it tends to be self-perpetuating, since
depression and anxiety are likely to
disrupt 24-hour rhythms further. An
irregular living schedule can aggravate
mood disorders. The old-fashioned
sanitarium rest cure was effective with
the "nervous" because it put the patient
on a regular schedule of sleep, activity,
and meals.
Insomnia
How is your sleep? Do you have
difficulty falling asleep? Or do you toss
and turn most of the night until you fall
into a deep sleep just hours before the
alarm goes off? A person suffering from
insomnia has difficulty initiating or
maintaining normal sleep, which can result
in non-restorative sleep and impairment of
daytime functioning. Insomnia includes
sleeping too little, difficulty falling
asleep, awakening frequently during the
night, or waking up early and being unable
to get back to sleep. It is characteristic
of many mental and physical disorders.
Those with depression, for example, may
experience overwhelming feelings of
sadness, hopelessness, worthlessness, or
guilt, all of which can interrupt sleep.
Hypomanics, on the other hand, can be so
aroused that getting quality sleep is
virtually impossible without medication.
In a study at the University of Oxford in
the United Kingdom, Allison G. Harvey,
PhD, and colleagues in the department of
experimental psychology determined that
even between acute episodes of bipolar
disorder, sleep problems were still
documented in 70 percent of those who were
experiencing a normal (euthymic) mood at
the time. These normal-mood patients with
bipolar disorder expressed dysfunctional
beliefs and behaviors regarding sleep that
were similar to those suffering from
insomnia, such as high levels of anxiety,
fear about poor sleep, low daytime
activity level, and a tendency to
misperceive sleep. Dr. Harvey concluded
that even when the bipolar patients were
not in a depressive, hypomanic, or manic
mood state, they still had difficulty
maintaining good sleep.
Delayed
Sleep Phase Syndrome
This is the most common
circadian-rhythm sleep disorder that
results in insomnia and daytime
sleepiness, or somnolence. A short circuit
between a person's biological clock and
the 24-hour day causes this sleep
disorder. It is commonly found in those
with mild or major depression. In
addition, certain medications used to
treat bipolar disorder may disrupt the
sleep-wake cycle. I often recommend
chronotherapy to patients. This therapy --
an attempt to move bedtime and rising time
later and later each day until both times
reach the desired goal -- is often used to
adjust delayed sleep phase syndrome. To
adjust the delayed sleep phase problem,
sleep specialists might also use bright
light therapy or the natural hormone
melatonin, particularly in depressed
patients.
REM Sleep
Abnormalities
REM sleep abnormalities have been
implicated by doctors in a variety of
psychiatric disorders, including
depression, posttraumatic stress disorder,
some forms of schizophrenia, and other
disorders in which psychosis occurs.
Special tests, called sleep
electroencephalograms, record the
electrical activity of the brain and the
quality of sleep. From these tests, we
know that in people who are depressed,
NREM sleep is reduced and REM sleep is
increased. Most antidepressant medications
suppress REM sleep, leading some
researchers to believe that REM sleep
deprivation relates to an improvement in
depressive symptoms. Yet Wellbutrin XL, a
common antidepressant, and some older
medications used to treat depression do
not suppress REM sleep. Researchers are
therefore still trying to determine the
connection between the REM sleep mechanism
and depression.
Irregular
Sleep-Wake Schedule
This sleep disorder is yet another
problem that many with Bipolar II
experience and in large part results from
a lack of lifestyle scheduling. The
reverse sleep-wake cycle is usually
experienced by bipolar drug abusers and/or
alcoholics who stay awake all night
searching for similar addicts and engaging
in drug-seeking behavior, which results in
sleeping the next day. This sleep
disruption and irregularity make it much
more difficult for the bipolar patient's
physician to treat him or her with
conventional medications and adjunctive
cognitive therapy. In most cases, the
patient needs to acknowledge the
drug-seeking behavior and get involved in
a recovery program such as Alcoholics
Anonymous, Cocaine Anonymous, or other
group. Talk therapy with a psychologist is
beneficial to many patients as they seek
to change destructive lifestyle habits and
learn new behaviors that will help them
adhere to a more normal sleep-wake
schedule.
Reprinted
from: Bipolar II: Enhance Your Highs,
Boost Your Creativity, and Escape the
Cycles of Recurrent Depression -- The
Essential Guide to Recognize and Treat the
Mood Swings of This Increasingly Common
Disorder by Ronald R. Fieve, M.D.
© 2006 Ronald R. Fieve, M.D.
Permission granted by Rodale, Inc.,
Emmaus, PA 18098.
Ronald
R. Fieve, MD, has published more than 300
scientific papers in the field of bipolar
and depression research. His work has been
published in such prestigious publications
as The Lancet, Nature, The American
Journal of Psychiatry, Archives of General
Psychiatry, The Journal of the American
Medical Association, L'Encephale, and
Lithium. Dr. Fieve has also written
two widely acclaimed books on mental
health, Moodswing and Prozac
(translated into five languages). He is
professor of clinical psychiatry at
Columbia Presbyterian Medical Center and
Columbia College of Physicians and
Surgeons, Columbia University, and
principal investigator, Fieve Clinical
Services, Inc. He maintains a private
practice in New York City.
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