Bipolar 2 From Inside and Out

Posts tagged ‘sleep disturbance’

Why Can’t I Sleep? Why Can’t I Wake Up?

Image by fizkes

Often in the past, I went to bed at my usual time but woke up at 4:45 a.m. and couldn’t get back to sleep, no matter what. It was like I had a hamster on a wheel inside my brain.

Other nights I would go to bed early and couldn’t get to sleep for hours. I tried reading, but sometimes I read till 2:00 a.m. with no sleep in sight. (I know you’re not supposed to read when you want to get to sleep because it activates your brain, but it’s been my nighttime habit for decades. When I find that I am reading the same paragraph twice, I know it’s time to knock off and fire up the CPAP machine.)

Then again there are days when I feel the need to nap in the early afternoon. I try to resist, but if I give in, there are no refreshing catnaps for me. I’m down for two and a half hours typically. Then the whole sleep-wake cycle gets off course.

And when I’m in the middle of a depressive episode, I’ve been known to stay awake all night, obsessing and catastrophizing. There are also days I can’t get out of bed in the morning, or all day in some cases, though I don’t usually sleep well after them.

What is it with all the sleep disturbances? Well, I have bipolar 2, so that may have something to do with it. An article published by the National Institutes of Health (NIH) says, “Sleep disturbance is a core symptom of bipolar disorder. The diagnostic criteria indicate that during manic episodes there may be a reduced need for sleep and during episodes of depression, insomnia or hypersomnia can be experienced nearly every day.” They also note that insomnia and hypersomnia are early warning signs, or “prodromes,” of a bipolar episode occurring. In fact, sleep disturbance is the number one prodrome for mania, and is recognized by approximately 80% of those suffering from it as an indication of an impending episode.

Webmd discusses a number of ways that bipolar disorder is associated with poor sleep: either insomnia or hypersomnia (over-sleeping); decreased need for sleep; a circadian rhythm sleep disorder; REM sleep abnormalities which can affect dreaming; and co-ocurring sleep apnea (around a third of people with bipolar also have sleep apnea, which is associated with excessive daytime sleepiness and fatigue). Bipolar meds have also been known to affect sleep-wake patterns, as well as co-occurring substance abuse disorders.

What are the consequences? Sleep deprivation has demonstrated detrimental effects on cognitive functioning, particularly in teens and young adults. This has been observed in performing psychomotor vigilance tasks, working memory tasks, and cognitive processing tasks. No wonder a series of sleepless nights can result in a foggy or fuzzy-headed feeling!

Unfortunately, the advice given for how to counter the effects of sleep disturbance in bipolar disorder is almost indistinguishable from the advice given to the general population, such as incrementally moving bedtime and waking time until the desired period of sleep is reached; and not using electronics such as computers, cellphones, and TVs near bedtime. Some preventives that have worked with bipolar patients have included bright light therapy in the morning and the use at bedtime of supplements containing the naturally occurring hormone melatonin that the body releases in response to darkness.

My own experiences with sleep deprivation and bipolar disorder have been a mixed bag. For many years before I was diagnosed, I was subject to the difficulties caused by shift work, either third or second shift. (When I was on second shift, we sometimes extended our sleepless periods by playing cards or midnight miniature golf after the shift was over.) Third-shift work made me too tired to drive safely, especially if I was also working first shift the next day, which sometimes happened. My husband pitched in and picked me up on those days. My friends knew never to call me before noon.

For a while I took a prescribed sleep aid, but sometime during the last year realized that as my sleep-wake cycle was regulating to a more “normal” pattern, and that the sleep I got without the meds was more refreshing and conducive to clear thought in the morning. So I quit taking it, with the approval of my psychiatrist. Even though I work at home and make my own hours, my work schedule has become predictable as well. Now I wake around 6:00 or 7:00 a.m., check my emails and timeline, have some breakfast and start my work (when I have some). I break for lunch, then resume work in the early afternoon. (And pray I don’t get any more work that day, as sometimes happens.)

As for getting to sleep, it’s usually not a problem (except when it is). Any more, I take my nighttime meds, read for about 30 minutes, and drift off to sleep normally. I usually only need a nap if extra work requires that I stay up late in the evening or get up very early in the morning.

So, does “Sleep, that knits up the ravelled sleave of care,” as Shakespeare described it, exist for people with bipolar disorder? I’d say, not for everyone, but when it does, it’s always welcome. We all have our various sorts of “ravelled sleaves” that need tending to.

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Not Breathing Affects Our Mental Health

My husband and I both have sleep apnea. We also both have depression, or at least he does and I have bipolar disorder with a pretty hefty depressive bent.

Sleep apnea is a medical condition in which a person stops breathing multiple times a night. The body responds to this by resuming breathing after a second or two, but sleep disruption has already occurred. For my husband, this occurs up to 60 times a night, while it happens to me more like six times. (Technically, my version is called “hypopnea” (hypo+pnea – low+breath; apnea, a+pnea – no+breath.))

The body depends on breathing, of course, for oxygen, but it also depends on sleep – which is disrupted in sleep apnea – for proper functioning. REM sleep, for example, is vital for dreaming, which has multiple beneficial effects on the body and mind. REM sleep has been known to be altered in depression, and studies have suggested that it is involved in modulating mood symptoms, including psychological distress in general.

One of the more observable symptoms of sleep apnea is loud and prolonged snoring, which both my husband and I have suffered from. While I was traveling with my mother, she even requested that I let her go to sleep first since my snoring kept her awake.

But what does sleep apnea actually do to the sufferer’s brain? Surely lack of oxygen to the brain has some effect.

Indeed it does.

According to research conducted at UCLA, “gasping during the night that characterizes obstructive sleep apnea can damage the brain in ways that lead to high blood pressure, depression, memory loss, and anxiety.”

Sleep apnea has been associated with difficulty concentrating, memory problems, poor decision-making, depression, and stress. Psych Central reports that untreated sleep apnea increases the chance of anxiety by over three and a half times; depression, by more than three times; severe psychological distress, by not quite three times; and suicidal thoughts, by more than two and a half times. Sleep apnea has also been associated with PTSD. The Journal of Clinical Sleep Medicine recommends that “in individuals with [obstructive sleep apnea] and psychiatric illness, treatment of both disorders should be considered for optimal treatment outcomes.”

Studies suggest that sleep apnea is linked with changes in at least two neurotransmitters in the brain (GABA and glutamate) that combine and coordinate signals that help regulate emotions, thinking, and some physical functions. Researchers plan to investigate whether treatments for sleep apnea will help these brain chemical levels return to normal.

SSRIs (selective serotonin reuptake inhibitors) such as fluoxetine and sertraline (Prozac and Zoloft) are thought to be valuable in treating sleep apnea. One study indicated that SSRIs may be a good treatment option for [sleep apnea], particularly for those [patients] with epilepsy. Another study showed a link between “having sleep apnea and increased odds of having a mental health issue” or symptoms such as anxiety or thoughts of suicide.

Treatments for sleep apnea include dental appliances to be worn while sleeping, lifestyle changes, and even surgeries. These treatments sometimes address snoring directly, but not the underlying mechanism. The more effective treatment is “positive air pressure,” delivered by CPAP machines.

CPAPs use positive air pressure to keep the sleeper’s airway from collapsing, which is what impedes their breathing and jolts thie brains into resuming it. They consist of a unit that generates air pressure, a hose and mask to deliver it, and assorted straps to keep the hose in place throughout the night. The masks can be ones that cover the entire nose and mouth or cannulas that are simply placed in the nostrils. There are also cushions on the masks or available separately that reduce discomfort as well as waking up with “mask face.” Many people find the masks uncomfortable to wear all night, but others use them not only at night but also for naps. Unlike a ventilator, the CPAP doesn’t breathe for a person. It allows them to breathe more effectively on their own.

Diagnosing sleep apnea requires a “sleep study” ordered by a doctor. Assorted leads are attached to the subject, who then spends all night sleeping (or trying to). Breathing rate, heart rate, oxygen saturation, and other parameters are measured and a record is kept of the number of times the subject stops breathing during the night. This is sent to the doctor, who can then prescribe a CPAP unit and mask.

Dan and I both use CPAP machines. They are a bit inconvenient, especially when we travel and have to take power cords so we both can use them at the same time (and power converters when we travel abroad). When it comes to packing, the machines are a bit bulky and somewhat heavy. Still, we take them with us religiously.

Has sleep apnea treatment improved our mental health? It’s hard to tell, especially since we’re both taking SSRIs anyway. I know correlation isn’t causation, but our depression and bipolar have certainly eased up since we started getting treatment and our sleep cycles have become more regular. But if all it does is stop the snoring, that’s still a win for us.

So, if you snore a lot and have mental health issues, you might want to be tested for sleep apnea and treated if you do. Like chicken soup, it can’t hurt and might help.

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Hypomania, Shopping, and Sleep

I hate shopping. Loathe it. Grocery shopping. Clothes shopping. Shoe shopping. Practically the only thing left for me is online shopping, and that can be treacherous – and not because I can so easily spend too much money.

Online shopping can push me over into hypomania. So can thinking about online shopping.

Recently, our house was destroyed by a tornado. We lost everything. And we have to replace everything. (Fortunately, our insurance company is paying for most of the lost items, as well as rebuilding the house.)

When I first got the inventory of things that needed replacing, I was too overwhelmed to do much about it. A window-shopping trip to La-Z-Boy left me bereft of spoons, as shopping always does. So I turned to the internet.

Do you have any idea how many companies are willing to sell me chairs, sofas, rugs, computer desks, jewelry armoires, electric fireplaces, and even walking sticks (to mention but a few items)? Lots. Lots and lots. Now I even get messages from many of them on my email and Facebook feed.

I have spent literally hours browsing online. And then I try to sleep. It’s an instant case of “Hamster Brain,” as my friends and I call it. I can’t sleep, even with my prescribed sleep aid and prescribed benzo. My mind starts whirling and my thoughts start racing.

Hypomania takes over. Oh, I don’t run to my computer and start ordering stuff. I’m keeping hands off my PayPal account, for the most part. But I lie in bed, eyes closed, trying to picture every purchase in what will be its new setting. I compare various color schemes for each room in the house, then change them each night – gold, brown, and cinnamon for my study? Blue and green with coral for the living room? And, oh, God, what about the bathrooms and the kitchen? I even arrange the furniture in my head – which wall will the computer desk go against? What will go beside the chairs? Tea cart? End table? Should we have a corner breakfast nook or a proper dinette set?

And how do I explain to my husband what my visions are? I can’t even decide between boho and country comfy. I can’t even define for him what I mean by boho. How do I keep him from sprinkling the house with 50s pieces (now called mid-century)? How can I integrate his treasures without spoiling my visions?

Most nights now I am up until 2:30 at least, which is when I take the benzo. When I wake, though, the hypomania is not over. It’s back to the computer with a new thing to search for, adding item after item to my favorites lists, comparing prices. I spend hours doing this. I email pictures back and forth with my husband as he gets caught up in my frenzy. This afternoon I spent several hours online buying replacements for books that were ruined. Tonight may be another case of no sleep till who-knows-when.

I’d like to stop, or at least slow down. Realistically, I don’t have to do anything now. I certainly don’t have to order or even browse choices. The house will not be rebuilt until at least the spring and we have no place to store any purchases until then. It’s silly to make decisions now, when between now and then thousands more choices will become available.

If I keep going at the pace I’m at now, I will be supremely sleep-deprived by the time I actually need to make purchases. And between now and then I see myself with a copy of the floor plans, making little cut-outs of different-sized furniture and trying them out for size and fit like those sliding puzzles we used to do as kids.

I see my pdoc this weekend and I’m going to ask him what to do about the hypomania and the lack of sleep. I get hypomania so seldom and it usually goes away so quickly. It’s impossible to think about it continuing at this level and going on for months.

Of course, it’s too simple for someone to tell me to calm down, not to think about it until the time comes. This is hypomania. That’s exactly what I can’t do. Once again, my brain is in control and running riot. And it won’t shut up, not even when I really need it to.

Bipolar Moonshine

Honestly, the things they ask on Quora these days! Quora, for those of you not familiar with it, is a website that allows people to ask questions for “experts” to answer. Somehow, I have become one of the people that others come to with questions about bipolar disorder. (Also the Ivy League, but that’s another story.)

Some of the questions are serious, but others are less so. “If you could stay hypomanic all the time, why wouldn’t you?” “How can I get my bipolar dad to stay on his diabetes meds?” I actually had an answer for that: You can’t. And bipolar has nothing to do with it. 

I’ve answered a few of the questions if I had the time or if a good answer hadn’t already been given. Many of the answers are written by doctors, who can do a much better job than I.

Recently, however, I saw a question that I thought it wouldn’t take a medical degree to answer:

“Is bipolar disorder causally linked to lunar cycles?”

Impressed that the writer knew the difference between “causally” and “casually,” I responded:

“No. The cause, as far as we know, is a glitch in the brain between the synapses. There may also be a genetic or hereditary component. But nothing to do with the moon.”

To my surprise, I received a reply. The writer, while asserting that he or she was also bipolar, said that my response was “no answer at all” and incorrect. Acknowledging the genetic component I mentioned, the author then proceeded to enlighten me with an “unpublished hypothesis.” (He or she also claimed to be “a bipolar scientist,” though not a neurophysiologist.)

The argument was based on several points.

  • Sexual reproduction is always in response to lunar cycles.
  • This is based on gravity, illumination, and diurnal and lunar cycles/high tides.
  • Bipolar disorder is a disruption of sleep.
  • It first manifests at or near puberty, with the onset of hormonal cycles.
  • Something about teenagers having a different sleep cycle than adults, staying up later to reproduce while the parents sleep. (I can’t say I understood this part.)
  • During the full moon, hospitals and police report increases in both people out late at night and odd behaviors and emergencies.
  • Anecdotally, the writer noticed “elevated and depressed moods not necessarily linked to lunar cycles, but not necessarily independent of them either,” noting that “periods of mania occur during full and nearly full/new moon.”

The writer’s hypothesis, if I follow it correctly, is that bipolar disorder involves sleep-hormonal cycles related to the full moon, which evolved in the days before artificial lighting. This apparently gave a reproductive advantage of being awake at night because bipolar disrupts the sleep cycle. This is noted to be “an obvious evolutionary reproductive strategy.” There was more, but that was enough for me. (The writer admitted that statistics to prove any of this did not exist or had to be derived from “Bayesian statistical methods,” which one source I looked at called “a measure of the strength of your belief regarding the true situation.”)

So, where to start? First, if the writer thought he or she already knew the answer, why write in with the question? Obviously, to seek validation or to promote a theory (or to make me look like a fool).

I could answer each point individually. (I’m not a neurophysiologist either, but I do have some experience with rhetoric and logic. And bipolar.) But let’s just take a few.

Not all animals’ reproductive cycles are based on the moon, and neither are humans’. Women have menstrual cycles at all times of the month, and men don’t. (And what about bipolar men?)

Bipolar disorder can certainly cause a disruption of sleep, but is not caused by it. That is too simple an explanation for a complex disorder.

We’ll just skip that one about teenagers reproducing while parents sleep. Its connection with bipolar disorder is slim at best.

That one about the full moon is most likely anecdotal, as reported by police and emergency room workers, but no statistics (other than perhaps Bayesian ones) seem to bear this out. And the moon is full, nearly full, or new for more than half the month. Let’s also disregard the fact that bipolar cycles are seldom exactly a month in length. I had a depressive crisis that lasted several years.

Many causes have been theorized for bipolar disorder, from gut bacteria to early trauma to brain wiring. At the moment, as far as I know, the jury is still debating. Perhaps all of these are components of the cause, though I favor brain wiring as the principal cause. But given the actual science, I’m betting that the moon isn’t the answer.

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