Problems Thinking in Bipolar - The Sleep Connection

John McManamy Health Guide
  • This is the latest in our series of posts looking at thinking difficulties in dealing with bipolar disorder. As I noted in Problems Thinking, the pioneering diagnostician Emil Kraepelin referred to “amentia” in his description of what he described as manic-depression (a term he coined) way back in the early twentieth century. Similarly, there is widespread consensus among today’s experts that cognitive dysfunction needs to be regarded as a core feature of bipolar disorder.

    Typically, a sizable number of those with bipolar have to work their brains harder to accomplish a simple cognitive task and experience difficulty responding correctly to more complex challenges, even when moods are stable. The brain scans tend to reveal disruptions in various areas of the brain communicating with each other.

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    Part of this has to do with the overlap between bipolar and schizophrenia. Yes, the two are separate illnesses, but schizophrenia traits such as psychosis and cognitive dysfunction are no strangers to bipolar, either. The loss of cognitive function in schizophrenia may be far more profound and disabling, but even a slight loss in processing speed and related functions can pose enormous challenges.

    Another part of this has to do with stress, which has a way of knocking the cortical areas of the brain off-line. No surprise - those with bipolar tend to be vulnerable to stress. Two months ago, at the NAMI national convention in Chicago, Jill Bolte Taylor, author of “My Stroke of Insight,” told us that when the amygdala (involved in fight or flight) feels safe, the rest of the brain can do its job. “Happy amygdala? That’s the bottom line for me.”

    This week, we examine yet another impediment to our thinking. This concerns sleep and fatigue. In all my time listening to patients and facilitating support groups I never once encountered someone with bipolar who did not have major issues with sleep. Sleep dysregulation is a symptom of both depression and mania. "Fatigue or loss of energy" is listed as a symptom of depression, and the DSM-5 will include increased energy as a feature of mania and hypomania.

    But these disturbances are hardly restricted to mood episodes. Typically, these are difficulties we are contending with every day of our lives, and when it’s not our moods that are thrown out of whack it’s our thinking. 

    Even the chronically normal face similar challenges. All it takes is a bad night’s sleep for the brain to fail to boot up right. Four years ago, at the 2007 American Psychiatric Association annual meeting in San Diego, I attended a three-hour symposium devoted to hypersomnia and cognitive difficulties. The neurotransmitters of arousal are also the neurotransmitters of concentration, Stephen Stahl of UCSD told the gathering. These include norepinephrine, dopamine, acetylcholine, and histamine. Serotonin, he said is like an "anti-dopamine or anti-norepinephrine," which is why those talking SSRIs, he said, may feel flat.

    Other relevant neurotransmitters include glutamate (wake), GABA (sleep), and adenosine (sleep). Chardonnay, Leslie Lundt of Idaho State University let us know, is a GABA med. Along the same lines, adenosine is why "people would be stupid enough to pay four dollars for a cup of coffee."

  • Sleep-deprived individuals require more brain activation in order to process mental tasks. Brain scans reveal little activity in the dorsolateral prefrontal cortex until subjects are able to kick it up a notch. Mood disorders, hypersomnia, fatigue, and lack of concentration go hand in hand. According to Dr Stahl, hypersomnia can also be found on what he describes as the same arousal-concentration or hypersomnia-cognitive spectrum as depression, anxiety, sleep deprivation, numerous sleep disorders, ADD and even schizophrenia. These tend to involve the same brain circuits, suggesting treatment with the same drug.

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    This also challenges the entire DSM. Dr Stahl confessed to writing in a diagnosis "in order to get paid." Then, "I forget about it."

    In a similar fashion, at another forum that same year, I heard Frederick Goodwin, co-author of the definitive text on bipolar, emphasize the vital necessity of managing sleep, to the point of thinking of it as the primary illness if push came to shove.

    A 2002 National Sleep Foundation poll that found that more than one-third of Americans are so sleepy it interferes with their daily activities. A sleep loss of four hours equates to five to six beers, or blood alcohol of 0.095, over the legal limit. A 2003 study found that the mostly A students in a middle school population were more awake than C students.

    Meanwhile, a 1999 study of patients with their depression in remission found the most common residual symptoms were sleep disturbances (44 percent) and fatigue (26 percent). Another study found that these residual symptoms predicted depressive relapse.

    As I report in an article on mcmanweb:

    Modern times work against us. Back before electric lights, most people slept about ten hours. Now it's down to seven, with one third of us below six. Throw in shift work, jet travel, and the demands of having to be in two places at once, and one can see why many more of us - children included - fall victim to mood disorders.

    Clearly, we have our work cut out for us. The good news, though, is that by managing our sleep we stand a good chance of getting a handle on our illness, including our moods and our thinking. How to best manage your sleep is the topic of a future blog. In the meantime, you might want to ask yourself:

    When your brain fails to boot up, when you are having difficulties concentrating, are you also feeling fatigued? Did you have a bad night’s sleep? Is your sleep schedule thrown off? Did you over-exert yourself the previous day?

    How about if your thoughts are rushing at you a mile-a-minute? Can’t sleep? Too much energy?

    Sometimes, it can feel as if both extremes are occurring at once - this happens frequently with those of us in mixed states - fatigued but with racing thoughts, agitated but exhausted.

    Right now, my thinking is online. But there is a major catch. I stayed up past 2 AM the night before (my bad), and to contend with a physical ache I took two Tylenol PMs. I woke up thoroughly refreshed, but at 11:30 AM, three or four hours past my usual wake-up time. Thank heaven I work from home and can set my own hours. I couldn’t survive in a world that demanded I be in the same place every day, at the same time, eight or ten hours straight.

  • Maybe I would show up on time, but I’m not sure my brain would. I would be very interested in hearing from those of you who can manage this. Comments below ...

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    Previous posts:


    Issues in Bipolar: Problems Thinking


    Problems Thinking - A New Bipolar Conversation


    Bipolar Disorder and Problems Thinking

Published On: September 11, 2011