Bipolar Insomnia: Symptoms, Causes, & Treatments

What Is Bipolar Disorder?

Bipolar disorder, or manic-depressive illness, is a diagnosable mental health condition characterized by extreme mood swings that alternate between depressive and manic episodes. These episodes can disrupt daily functioning and relationships. While medication, therapy, and lifestyle changes are commonly used to manage symptoms, specific interventions may vary based on individual needs and the severity of the condition.

Bipolar disorder is characterized by a combination of:

• Depressive episodes: During depressive episodes, individuals may experience persistent sadness, loss of interest, low energy levels, and changes in appetite or sleep patterns.³
• Manic episodes: Manic episodes involve elevated moods, increased energy levels, racing thoughts, and impulsive behavior.

What Is Bipolar Insomnia?

Sleep disturbance is a primary symptom of bipolar. Depending on the individual, this may be less invasive but is still problematic. When the condition worsens, it may lead toward a dual diagnosis of insomnia in which one struggles to fall asleep, remain asleep, and acquire what is considered a healthy 7+ hours of sleep.^2,4

During manic episodes, individuals often experience heightened energy levels, racing thoughts, and an increased need for stimulation, leading to difficulty falling asleep or a reduced need for sleep. During depressive episodes, pervasive rumination, and emotions may make sleeping difficult.

It’s important to note that the impact of sleep goes beyond being a symptom of bipolar disorder. Poor sleep can also contribute to increased bipolar symptoms. Sleep deprivation or irregular sleep patterns can trigger or worsen episodes of mania or depression, leading to a cycle of disrupted sleep and heightened symptoms

Signs and symptoms of bipolar insomnia include:

• Irregular sleep patterns: Fluctuations between manic and depressive episodes can lead to irregular sleep schedules, contributing to sleep difficulties and disrupted circadian rhythms.
• Reduced need for sleep: During manic episodes, individuals may feel less need for sleep, leading to decreased sleep duration and increased wakefulness.
• Difficulty falling asleep: Manic episodes in bipolar disorder can cause racing thoughts at night and heightened energy levels, making it challenging to initiate sleep.
• Worries about falling asleep: Individuals with a history of sleep disturbance oftentimes worry that they will not fall asleep while lying down for rest. Shortly into an attempt to sleep, a rumination of automatic negative thoughts such as “I will never fall asleep,” “There is no point to going to bed,” and otherwise might occur—yielding a negative experience specific to bedtime.
• High levels of stress at bedtime: Beyond worrying about falling asleep, the spiral of negative thoughts and emotions may draw one’s focus toward otherwise upsetting thoughts that may have occurred throughout the day, in the past, or anticipation/worry about the future.
• Difficulty staying asleep: Increased arousal can disrupt the normal sleep cycle, resulting in frequent awakenings throughout the night. As one increases in frustration, falling back asleep may prove more challenging.
• Early morning awakening: Some individuals with bipolar disorder experience a pattern of waking up very early in the morning and being unable to fall back asleep.
• Dependency on medication for sleep: Out of desperation, individuals may begin trying supplements or other medications for sleep. While melatonin is oftentimes used as a non-addictive supplement, when that does not work, people may rely on OTC, prescription, and/or illegal substances for sleep. Doing this complicates the condition further, as one may become reliant on medications that have a diminishing effect over time and require a higher dosage.
• Poor memory or problem-solving: Without adequate sleep, one’s brain never fully recharges, leading to issues with memory and focus, which compromises one’s problem-solving ability.

Does Bipolar Disorder Cause Insomnia?

While bipolar disorder does not directly cause insomnia, the symptoms and episodes associated with the disorder can significantly contribute to sleep disturbances. Both depressive and manic episodes may contribute toward the development of insomnia, though it is more common during manic episodes. Co-occurring conditions, such as depression, may complicate bipolar with insomnia further.

If one is depressed and/or anxious and finds oneself ruminating on the past or worrying about the future, it becomes difficult to sleep, which may—over time—lead to insomnia. With manic episodes, individuals often experience heightened energy levels, racing thoughts, and an increased need for stimulation, which can make it difficult for individuals to relax and fall asleep, leading to insomnia.

Can Insomnia Cause Bipolar Disorder?

While insomnia can be a risk factor for developing bipolar disorder, it is not a direct indicator of bipolar disorder.² The diagnosis of bipolar disorder requires the presence of specific symptoms, such as manic or hypomanic episodes, depressive episodes, and distinct changes in mood and behavior.³ However, sleep plays a crucial role in regulating mood, emotions, and cognitive function. So, when sleep is consistently disrupted or insufficient, it can contribute to the development or exacerbation of a bipolar diagnosis.⁴

Insomnia can potentially trigger manic episodes in individuals with bipolar disorder. Sleep disruption and insufficient sleep can disrupt the delicate balance of neurotransmitters and circadian rhythms, contributing to mood dysregulation and increasing the likelihood of manic symptoms.² Poor sleep can also impact the effectiveness of mood stabilization treatments for bipolar disorder.

Additional Sleep Issues Related to Bipolar Disorder

Bipolar disorder can trigger additional sleep disturbances beyond what is typically classified as insomnia. Individuals with bipolar disorder may experience changes in sleep patterns, such as hypersomnia, fragmented sleep, or irregular sleep schedules.⁵ These disruptions can stem from the underlying neurochemical imbalances and dysregulation of mood associated with bipolar disorder, impacting the intricate mechanisms that govern sleep processes.

Sleep disturbances are very common in the general population. The prevalence of symptoms of sleep disorders ranges between 41% and 52% worldwide, with the most widespread symptoms being insomnia, followed by excessive daytime sleepiness, nightmares, difficulty falling asleep or maintaining sleep, poor sleep quality, sleep talking, sleepwalking, and obstructive sleep apnea.⁵

Other sleep issues common in people with bipolar disorder include:

• Irregular sleep/wake cycles: Bipolar disorder can disrupt the regular pattern of sleep and wakefulness, leading to fluctuations in sleep timing and duration. Individuals may experience periods of hypersomnia during depressive episodes or insomnia during manic episodes.
• Delayed sleep phase syndrome: This is a condition where an individual’s internal body clock is delayed, causing them to have a delayed sleep-wake schedule. Here, one may experience difficulties in falling asleep at a conventional bedtime and waking up in the morning.
• Nightmares: Though bipolar disorder does not directly cause nightmares, bipolar psychosis, or intense emotional experiences during manic or depressive episodes, can contribute to vivid dreams. Nightmares may be more frightening due to the heightened emotional states associated with the condition.⁶
• Restless legs syndrome (RLS): RLS is a neurological disorder characterized by uncomfortable sensations in the legs, often accompanied by an irresistible urge to move them.⁷ Comorbid cases of bipolar disorder with RLS do exist (lifetime prevalence of 37% for those with a mental health condition versus 15% for those without) and yield discomfort and an urge to move the legs while sleeping or attempting to fall asleep.⁸
• Obstructive sleep apnea (OSA): OSA is a sleep disorder where breathing is repeatedly interrupted during sleep due to the partial or complete collapse of the upper airway.⁹ While not directly caused by bipolar disorder, individuals with bipolar disorder may have a higher prevalence of OSA (around 24.5 for bipolar patients in a clinical setting).¹⁰ Complications can include excessive daytime sleepiness, impaired cognitive function, and increased risk of cardiovascular problems if left untreated.
• Hypersomnia: More common with depressive episodes, bipolar disorder can cause excessive sleepiness, leading to prolonged periods of sleep and difficulty waking up in the morning. Here, one may awake feeling groggy or unrefreshed despite extended sleep duration.
• Fragmented sleep: Fragmented sleep entails frequent awakenings during the night, leading to fragmented sleep. This can disrupt the normal sleep cycle and result in feeling unrested.
• Sleep-related anxiety: Bipolar disorder can contribute to heightened anxiety levels, leading to difficulty falling asleep due to racing thoughts, worries, or intrusive thoughts that interfere with sleep initiation.
• REM sleep abnormalities: Bipolar disorder has been associated with alterations in rapid eye movement (REM) sleep, including decreased REM latency, increased REM density, and increased duration of REM sleep.⁵ These abnormalities can affect the quality of sleep and contribute to symptoms such as vivid dreams or nightmares.
• Sleepwalking or other parasomnias: Bipolar disorder may increase the likelihood of experiencing parasomnias (abnormal movements, talk, emotions, and actions while sleeping), such as sleepwalking, night terrors, or sleep-related eating disorders. These disturbances in behavior during sleep can further disrupt sleep quality and contribute to daytime sleepiness.¹⁰

How to Get Better Sleep When You Have Bipolar Insomnia

Treating insomnia in individuals with bipolar disorder usually requires addressing the underlying bipolar symptoms to alleviate their impact on sleep. By effectively managing manic and depressive episodes through therapy, medication, and other individualized interventions, the sleep disturbances associated with bipolar disorder can be reduced.¹¹ This approach focuses on mood stabilization, energy level regulation, and addressing the root causes of sleep disruptions.

Strategies for managing bipolar insomnia include:

• Developing healthier sleep routines: Set a regular bedtime and wake-up time, even on weekends, to help regulate the body’s internal clock and promote better sleep.
• Using light as a tool: Our body’s circadian rhythm relies on traditional time to physiologically indicate waking and sleeping hours. Accordingly, exposure to light in the day and less at night can help the body recognize when it is time to wake up and sleep. Natural light during the day is more effective than artificial lighting.¹²
• Avoiding substance consumption before bed: Avoid consuming caffeine, nicotine, and alcohol, especially close to bedtime, as they can interfere with sleep quality and exacerbate insomnia symptoms.
• Developing a sleep paradise: Make sure your bedroom is dark, quiet, and cool to your comfort level. Use blackout curtains, earplugs, or a white noise machine to minimize disruptions and create a conducive sleep environment. This may also involve using aromatic scents and otherwise.
• Winding down before bed: Establish a relaxing bedtime routine to signal to your body that it’s time to sleep. Reading, taking a warm bath, engaging in relaxation techniques, listening to calming music, et cetera may help here. You know yourself best and should try a variety or combination of strategies until finding one that works. When you do, stick with it.
• Consistently exercising: Engaging in regular physical activity during the day helps regulate sleep patterns and improve overall sleep quality. As a word of caution, avoid exercising too close to bedtime, as it may increase alertness and make it harder to fall asleep.
• Limiting daytime napping: Minimize daytime napping or restrict it to short power naps (20 minutes max) to prevent excessive sleepiness during the night.
• Managing stress: Employ stress management techniques such as mindfulness, breathwork, meditation, journaling, or other activities that help you relax.
• Avoiding electronic stimuli before bed: The blue light emitted by electronic devices is not only bad for your eyes but can interfere with the body’s production of melatonin, a hormone that regulates sleep.¹³ Avoid using smartphones, tablets, laptops, et cetera close to bedtime. Unfortunately, this includes falling asleep with the TV on as well.
• Adjusting medication (where appropriate): Some medications may inherently compromise sleep. Here, you should consult with your healthcare provider about the possibility of adjusting your medication regimen to help address sleep disturbances if medication is a contributing factor.

Remember, implementing lifestyle changes should be done in consultation with a healthcare professional who can provide personalized guidance and support based on your specific needs and condition.

Treatment of Comorbid Insomnia & Bipolar

The treatment of comorbid bipolar insomnia typically involves a multifaceted approach including a combination of medication, psychotherapy, and other lifestyle changes. Medical help entails physiological considerations that may require medication and/or changes in nutrition, exercise, et cetera. Psychological help may entail an exploration and working through of maladaptive thoughts, emotions, and behaviors.

Before diagnosis insomnia, it is important that a primary care physician (PCP) rules out any other physical ailments (e.g., RLS, narcolepsy, sleep apnea). Bipolar disorder and insomnia are both impacted by chemical imbalances, which bipolar treatments aim to re-balance. Individuals should seek treatment for symptoms sooner than later, as this may greatly minimize negative impacts to well-being before they become debilitating.

Medication

Given that the core conditions of bipolar disorder and insomnia are mutually exclusive, though they may compromise one another, medications for bipolar disorder primarily target mood regulation and stabilization rather than directly addressing sleep disorders. While these medications can indirectly improve sleep by managing bipolar symptoms, additional medications may be necessary to specifically target and alleviate insomnia symptoms.

Obtaining pharmaceuticals should always be done under the advisement of a qualified healthcare professional. Psychiatrists or other prescribing physicians specializing in bipolar disorder are primarily responsible for prescribing and managing medications for bipolar insomnia. Given advancements in telemedicine, online psychiatrists can and regularly do provide virtual consultations and prescriptions for medications treating bipolar disorder and associated sleep disturbances.

Therapy

Therapy is a crucial component in the treatment of comorbid bipolar insomnia. Different therapeutic modalities can help individuals manage their bipolar symptoms while addressing the underlying causes of sleep disturbances. Fortunately, there are many approaches that may assist that vary on individual needs. Cognitive-behavioral therapy (CBT) is among the most evidence-supported practices for treating bipolar disorder and insomnia.

Bipolar disorder and insomnia can be treated with therapy techniques such as:

• CBT for Insomnia (CBT-I): CBT-I is a structured therapy that focuses on identifying and changing negative thoughts and behaviors related to sleep. It helps individuals develop healthy sleep habits, manage stress, and address the underlying causes of insomnia, which can alleviate sleep disturbances associated with bipolar disorder and improve overall sleep quality.
• Dark Therapy: Dark therapy is an approach in which complete darkness is used as a mood stabilizer in bipolar disorder.¹⁴ This is essentially the opposite of light therapy for depression. Absolute darkness minimizes the interference of externalized stimuli that compromise sleep.
• Hypnosis for sleep: Hypnosis for sleep utilizes hypnotherapy to induce a deeply relaxed state. By activating the parasympathetic nervous system, one attains a natural state of relaxation in which feelings of stress, anxiety, and other negative feelings subside. Without said distraction, it becomes much easier for one to fall and remain asleep.
• Interpersonal and social rhythm therapy (IPSRT): IPSRT is specifically designed for individuals with bipolar disorder. It aims to stabilize daily routines and regulate social rhythms to establish a consistent sleep-wake schedule.¹⁵ By promoting regularity in daily activities and sleep patterns, IPSRT can help manage bipolar symptoms and reduce sleep disruptions.
• Sleep restriction therapy: Sleep restriction therapy is a form of CBT that involves limiting the time spent in bed to match the individual’s actual sleep duration.¹⁶ By optimizing sleep quality and reducing time spent in bed awake, sleep restriction therapy can address both insomnia symptoms and the sleep disturbances associated with bipolar disorder. As many couples’ counselors would attest, bed should be reserved for sleep and sex with other activities being conducted elsewhere.
• Mindfulness-based therapies: Therapies including mindfulness-based stress reduction (MBSR) or mindfulness-based cognitive therapy (MBCT) can help individuals learn and develop skills for managing stress, regulating emotions, and enhancing overall well-being. By reducing stress and grounding oneself in the moment, these therapies can indirectly improve sleep quality and alleviate both bipolar and insomnia symptoms.
• Dialectical Behavior Therapy (DBT): Initially developed for the treatment of borderline personality disorder, DBT is a comprehensive therapy that combines elements of CBT and mindfulness. It focuses on emotional regulation, distress tolerance, and interpersonal effectiveness. By addressing mood dysregulation and teaching skills for managing intense emotions, DBT can contribute to improved sleep and help manage bipolar symptoms.

Finding a therapist with specialized training and experience in treating bipolar insomnia may begin by searching the web. Utilizing an online therapist directory can be helpful. Many directories allow users to filter their search based on specific criteria, such as therapy type, specialization, location, hours, managed care reimbursement, et cetera. The best way to find the right therapist to address this would be to seek therapists who specifically mention expertise in bipolar disorder and sleep disturbances.

In My Experience

Bipolar insomnia is a debilitating condition with substantial implications, especially if gone untreated. Understanding the impact of sleep on mental health is an important consideration for one’s recovery effort. The relationship between sleep and mental health (including bipolar disorder) is multifaceted, and addressing sleep disturbances is an important aspect of managing bipolar disorder effectively.

Therefore, effective treatment requires something more comprehensive in which sleep disturbance is addressed while healthy sleep habits are promoted. Beyond traditional psychotherapy, one may require the expertise of a psychiatrist (prescribing physician), somnologist (sleep specialist), and others. By addressing the condition both at the core and with individual symptoms, one has an increased chance of finding and maintaining a healthy balance.

Your struggle with insomnia and bipolar may be unique to you, but you’re not alone. Remember, help is available and begins by taking the first step. Talking to a therapist or reaching out to a trusted friend or family member can significantly affect how you feel. For additional support, please visit the suggested sites for further reading below.