Sleep and Hypomania—The ABCs of Getting your ZZZs

Sleep and Hypomania—The ABCs of Getting your ZZZs

The prevalence and consequences of insomnia and poor quality sleep are well known. Worldwide, >60 million adults are affected by sleep disorders (1) and 50% of adults, at some point in their lives, are affected by insomnia (2). Between 10% and 15% of the US population experiences insomnia lasting >6 months (3,4). Insomnia causes significant physiologic morbidity including increased cortisol levels, decreased glucose tolerance, and increased activity of the sympathetic nervous system (5). Long-lasting insomnia can lead to impaired functioning during the waking hours and increased incidence of accidents (6). Within the mood spectrum, persistent insomnia may be a risk factor in developing depression (7). How then do these staggering statistics impact the realm of hypomania and elevated mood?

The reciprocal relationship between mood and sleep

There are at least three connections between disruption of sleep and elevated mood. It has been clinically and experimentally shown that sleep deprivation is associated with the onset of hypomania or mania in patients susceptible to mood disorders (8). When 11 studies were reviewed totaling 631 patients
with bipolar disorder (9), sleep disturbance was the most common symptom of mania, reported by more than three quarters of patients, and the sixth most common symptom of bipolar depression, reported by one fourth of the number of patients. Insomnia is also a significant and common problem among patients with bipolar disorder even when they are euthymic. In a recent study (10), ten percent of euthymic patients with bipolar disorder reported a significant sleep disturbance including impaired sleep efficiency, increased anxiety about poor sleep, and decreased daytime activity levels due to lack of sleep. Lastly, it has been suggested that the disruption of the sleep-wake cycle may be a causative factor in the development of bipolar disorder, postulating that these patients have a genetic diathesis for circadian rhythm instability. These authors propose (11,12) that psychosocial stressors may cause disrupted routine and sleep, which consequently disrupts already vulnerable circadian rhythms and may trigger a mood episode. Sleep quality is one of the most objective measures of improvement or deterioration in bipolar disorder and may serve as either a signal, or a trigger of manic, or hypomanic episodes (13,14). Lack of sleep may cause a switch from depression to mania in as many as 6% of vulnerable patients (15). Therefore, insomnia and disruptive sleep are a consequence of a mood episode, may serve as a signal of an oncoming mood episode, or be a cause of an elevated mood episode. Disrupted sleep and circadian rhythms may also have a causative role in the development of bipolar disorder itself. It is critical, therefore, for the clinician to monitor sleep-wake cycles and intervene quickly if sleep is disrupted.

How much sleep is enough?

The notion that everyone requires 8 hours of sleep is a myth, and is seldom true for even non-mood disordered patients. In patients with elevated mood, however, the length of sleep necessary for optimum functioning is further complicated by the fact that patients with bipolar disorder, even when relatively euthymic, are often short sleepers. Hyperthymic individuals who function at adequate or even superior levels may require only 4 to 5 hours of sleep over long periods of time. In these individuals, short sleep patterns do not necessarily indicate pathology. As with many areas of elevated mood, assessment of the patient’s functioning is the key issue. If a patient has been stable on a short sleep pattern for many months or even years and is functioning well, the pattern need not be changed nor seen as an element of pathology. It is of significance, however, if there is a recent change in sleep pattern. The fact that a mood disordered patient who has traditionally slept 6 to 7 hours but begins to sleep 3 to 4 hours per night is a red flag warning, and is a potential sign of an incipient mood change. When necessary, input from other sources such as the patient’s spouse or bed partner may be necessary to adequately assess the quality and quantity of the patient’s sleep.

Evaluation of sleep in elevated mood

Because of the reciprocal relationship between sleep and mood fluctuations, one may assume that all disordered sleep is referable to the patient’s hypomania or mania. Especially during an initial evaluation or early in treatment however, this assumption should not be made until a thorough evaluation of other causes of sleep disturbance is made. Short-term or transient insomnia in a hypomanic patient can also be due to multiple factors such as those listed in Table 11.1.

When evaluating a mood disordered patient with a significant sleep problem, the evaluation should consist of a clinical history, a sleep history, a physical examination, and, when necessary, laboratory assessments. The clinical history should focus on the duration of the sleeping problem.

  • How long has the patient had difficulty with sleep?

  • When in the night does the problem occur?

  • Is there

    • difficulty falling asleep?

    • awakening in the middle of the night (sleep continuity disturbance)?

    • early morning awakening?

The sleep history should obtain information about the lifestyle and sleep environment including cigarette smoking, alcohol and caffeine intake, levels of exercise, and when bedtimes and arising occur. It may be helpful to use a standardized questionnaire such as the Pittsburgh Sleep Quality Index (PSQI) to document these issues (Table 11.2).

A physical examination should focus on ruling out medical conditions and the treatments that are known to cause insomnia including the factors in Table 11.3.

The patient should be screened for the use of various medications and other substances that are known to cause insomnia as shown in Table 11.4.

A physical examination should also include a neurologic examination, assessment for signs of vascular disease, or peripheral neuropathy, assessment of the upper airway and a general examination of cardiac and pulmonary
function (16). If there is suspicion of a sleep-related breathing disorder, periodic leg movements, or nocturnal seizure disorder, polysomnography, a nocturnal electroencephalograph (EEG), or electromyography (EMG) may be helpful. These tests, however, are not routinely performed in the patient with elevated mood unless there are signs of these disorders. As with most patients with elevated mood who are to be placed on medication, a battery of laboratory screening tests including routine electrolytes, chemistries, blood urea nitrogen (BUN), creatine, liver function, thyroid-stimulating hormone (TSH), and complete blood count (CBC) should be obtained.

TABLE 11.1 Factors causing short-term or transient insomnia in hypomanic patients

Emotional distress or bereavement

Initiation or discontinuation of pharmaceuticals

Use/abuse/withdrawal of alcohol or recreational drugs

Recent onset of a physical or painful illness

Work shift changes

Jet lag

TABLE 11.2 Pittsburgh sleep quality index

Pittsburgh Sleep Quality Index (PSQI)

The following questions related to the patient’s usual sleep habits during the past month only. Answers should indicate the most accurate reply for the majority of days and nights in the past month. Answer all questions.

During the past month:

1. What time have you usually gone to bed?_____

2. How long has it taken you to fall asleep each night? _____(in minutes)

3. What time have you usually gotten up in the morning?_____

4. How many hours of actual sleep did you get at night? This may be different than the number of hours you spend in bed) _____(in hours)

5. How often have you had trouble sleeping because you…

Place the number in the parentheses in the box that matches your best answer

Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three or more times a week (3)


Could not go to sleep within 30 minutes


Woke up in the middle of the night or early morning


Had to get up to use the bathroom


Could not breathe comfortably


Cough or snore loudly


Felt too cold


Felt too hot


Had bad dreams


Had pain


Other reason(s), please describe how often you have had trouble sleeping because of this reason(s):

During the past month: Very good (0), fairly good (1), Fairly bad (2), Very bad (3)

6. How would you rate your sleep overall?_____

Not during the past month (0), less than once a week (1), Once or twice a week (2), Three or more times a week (3)

7. How often have you taken medicine (prescribed or “over the counter”) to help you sleep?_____

8. How often have you had trouble staying awake while driving, eating meals, or engaging in social activity?_____

No problem at all (0), Only a very slight problem (1), Somewhat of a problem (2), a big problem (3)

9. How much of a problem has it been for you to keep up enough enthusiasm to get things done?_____

10. Do you have a bed partner or roommate? _____Yes _____No

If you have a bed partner or roommate ask them how often in the past month you have had…

Not during the past month (0), less than once a week (1), Once or twice a week (2), three or more times a week (3)

a. Loud snoring_____

b. Long pauses between breaths while you sleep_____

c. Legs twitching or jerking while you sleep_____

d. Episodes of disorientation or confusion during sleep_____

e. Other restlessness while you sleep, please describe _____. How often?_____


Each component has a score of 0 to 3, with 0 indicating no difficulty and 3 indicating severe difficulty. The seven components are combined to give one global score of 0 to 21, with 0 indicating no difficulty and 21 indicating severe difficulties in all areas.

Component 1—Subjective Sleep Quality

Component Score_____

Component score = question 6 score

Component 2—Sleep Latency

Component Score_____

1. If question 2 score is …

≤15 minutes; component score = 0

16-30 minutes; component score = 1

31-60 minutes; composite score = 2

>60 minutes; composite score = 3

2. Question 5a score


Sum of question 2 score + question 5a score is …

If 0, then component score = 0

If 1-2, the component score = 1

If 3-4, then component score = 2

If 5-6, then component score = 3

Component 3—Sleep Duration

Component Score_____

For question number 4:

If >7, then component score = 0

If 6-7, then component score = 1

If 5-6, then component score = 2

If <5, then component score = 3

Component 4—Habitual Sleep Efficiency (HSE)

Component Score_____

HSE% = (# hours asleep—# hours in bed) × 100

If >85%, then component score = 0

If 75-84%, then component score = 1

If 65-74%, then component score = 2

If <65%, then component score = 3

Component 5—Sleep Disturbance

Component Score_____

Sum of score for question 5b through 5j

If 0, then component score = 0

If 1-9, then component score = 1

If 10-18, then component score = 2

If 19-27, then component score = 3

Component 6—Use of Sleep Medication

Component Score_____

Component score = question 7 score

Component 7—Daytime Dysfunction

Component Score_____

Sum of question 8 score + question 9 score

If 0, then component score = 0

If 1-2, then component score = 1

If 3-4, then component score = 2

If 5-6, then component score = 3

Global Score

Global PSQI Score_____

Add the 7 components together

Adapted from Buysse DJ, Reynolds CF III, Mont TH, et al. The pittsburgh sleep quality index: A new instrument for psychiatric research and practice. Psychiatry Res 1989;28(2):193-213.

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Jul 29, 2016 | Posted by in GENERAL | Comments Off on Sleep and Hypomania—The ABCs of Getting your ZZZs
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