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Bipolar Disorder: a Sleep or Rhythm Problem?

Bipolar Disorder: a Sleep or Rhythm Problem?

As already discussed in a previous text, it is very common for patients with psychiatric disorders to report complaints related to sleep disorders, and among them, bipolar disorder. Previously known as manic-depressive illness, this disorder is characterized by the alternation, from time to time, from a depressive condition to a hyperactive (manic) condition.

When we talk about sleep duration, depression and mania have similar characteristics between them, as well as different ones. Both cases are characterized by a decrease in total sleep time. However, while depressed individuals report complaints related to insomnia, individuals with mania have a feeling of less need for sleep time.

In general, when a person diagnosed with bipolar disorder sees a doctor if they complain about their sleep pattern, sleep-inducing drugs are commonly prescribed for acute treatment of the problem. In the short term, it may solve the initial complaints of insomnia, but it will possibly create a snowball – which will get worse as time goes on.

Some studies published in recent years are associating the incidence of bipolar disorder with circadian rhythm disturbances. As mentioned in other texts on this blog, basically all our body cells, hormones, gene expression, among other physiological events in our body have a stable rhythm of about 24 hours, being regulated by the interaction of the individual’s internal rhythm with information, the main one being the light/dark cycle.

A study by Japanese researchers published in 2018 in the journal Psychiatry and Clinical Neuroscience conducted a literature review on the interaction of circadian rhythmicity and bipolar disorder. And some conclusions were based on the works consulted

Circadian rhythmicity characteristics

In individuals with bipolar disorder, it is common to see a delayed sleep-wake rhythm phase, meaning individuals have a tendency to sleep later and wake up later than individuals who do not have bipolar disorder. And this feature is observed even when the person is not in a depressive condition.

Still referring to the expression of rhythm, using a specific questionnaire to assess the expression of the biological rhythm, it was observed that individuals with bipolar disorder have problems related to rhythmicity, which is to be expected in individuals with psychiatric disorders.

One of the most striking physiological biological rhythms of circadian rhythm expression is the secretion of melatonin, which, despite being called the sleep hormone, is actually a hormone whose secretion occurs at night, and serves as an endogenous signal throughout our body and circadian timing system. The studies surveyed identified abnormalities in the secretion of melatonin in bipolar individuals, even when they are in the controlled period of bipolar disorder. These abnormalities are characterized by a delayed peak and decreased secretion of melatonin in individuals.

When we talk about circadian rhythms, we are talking about a timing system present at the cellular level, that is, every cell has a circadian timing system that are regulated and synchronized from the main oscillators of the human body, the suprachiasmatic nuclei and their interactions with hypothalamic regions. Dysfunctions in gene expressions that are part of the circadian rhythm timing system at the cellular level seem to be associated with bipolar disorder.

Studies show that individuals with depressive episodes usually have a delayed sleep phase, so that the prevalence of depression is higher in individuals who belong to the evening chronotype. However, people with bipolar disorder have an even greater delay in the sleep phase, and with lower levels and more delay in melatonin secretion than people with other types of depressive disorders. For these characteristics, the authors suggest that the detection of circadian rhythm dysfunctions can be used as a marker for clinical follow-up as well as used for the diagnosis of bipolar disorder.

Regarding the daily interaction of the individual’s circadian rhythm with the environment, it was observed that socially imposed temporal challenges, with sudden changes in social hours, such as work or study, negatively affect and can be triggers for the onset or recurrence of mood disorders in individuals with bipolar disorder. Thus, a destabilization of the circadian rhythm can be a predictor of the occurrence of episodes of mood change.

 Treatment focused on improving circadian rhythm

Remember that it is always necessary to search for competent health professionals, such as psychiatrists, sleep doctors, therapists, among others. The search for trained professionals is essential to improve the clinical picture. This article is aimed at information about the most recurrent therapies for the improvement of bipolar disorder when the focus is on the treatment of circadian rhythm disorder.

Lithium is one of the most recommended drugs for treating mood disorders, and it is also used to help stabilize the circadian rhythm. Lithium has the ability to help correct the circadian rhythm phase advance that is characteristic in patients with bipolar disorder.

Talks about melatonin supplementation for the treatment of sleep and rhythm disorders are not news. Thus, it is expected that it will also be used in order to correct the expression of the circadian rhythm. Additionally, melatonin is also effective for treating mood swings in patients with bipolar disorder through circadian rhythm regulation.
Sleep hygiene procedures, such as manipulation of the light/dark cycle through light therapies in individuals with depressive symptoms and with dark therapies for individuals with mania symptoms, seem to be efficient in the treatment to avoid severe clinical conditions. Another strategy used is to combine psychotherapy with routine standardization to prevent possible outbreaks, as well as to improve depressive episodes. And finally, the use of specific Cognitive Behavior Therapy for patients with bipolar disorder is also effective in preventing and improving clinical conditions.

In order to follow the circadian rhythm routine and, consequently, the sleep routine, there are some alternatives on the market. The use of these technologies in the detection of disorders, clinical follow-up and final evaluation are already a reality beyond the academic environment.

In a simpler way, you can use the Sleep Diary, which is referred to on the internet in several academic articles, or use online digital diaries already available on the market. Application is Sleep Diary da Condor Instruments used as an accessory to the Condor Instruments aimed at professionals who want to apply Cognitive Behavioral Therapy-I and other therapies that need to monitor their clients’ sleep. Among the main features are: application with simple interface, access control performed by the professional and data sent automatically to Condor’s server Condor.

The use of actimetry, or actigraphy, is a reality for monitoring the circadian rhythm and sleep in patients with psychiatric disorders, even used in clinical research with patients with bipolar disorder.

Most of the time the device is similar to a wristwatch; the actigraph is a modern device used to monitor activity and rest cycles. The objective is to gather a series of important information for the study of the sleep and wakefulness rhythm.

The patient must wear it attached to the wrist, in the non-dominant arm, throughout the evaluation period. From the analysis of the actigraphy, it is possible to identify sleep disorders and circadian rhythmicity, offering the assistant physician the time of the patient in bed, sleep episodes occurring throughout the day and a series of other data that will be essential for diagnosis and treatment of the problem. The most modern models have temperature and light sensors, which allow an even deeper analysis of the expression of physiological rhythmicity, as well as the patient’s interaction with the natural environment.

The importance of evaluating the expression of the circadian rhythm of patients with bipolar disorder is clear, in order to provide a more efficient and lasting treatment, which will effectively solve the individual’s problem and promote a definite improvement in the quality of life.



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