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Section 6
Sleep Problems

Question 6 | Test | Table of Contents

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In the last section, we discussed conditions that may co-occur with bipolar disorder. These conditions are autoimmune disorders, borderline personality disorder, and cyclothymic disorder.  We also presented ways to diagnose these comorbid conditions along with ways to treat clients with comorbid conditions.

One of the core problems in bipolar disorder as you know is instability.  Without some sort of stability, a bipolar client’s body chemistry becomes confused. 

In this section, we will present the traits of the sleep-wake cycle and how it affects bipolar clients:  social Zeitstorers, social Zeitgebers, and a regulated sleep pattern.

3 Traits of the Sleep-Wake Cycle

♦ 1. Social Zeitstorers
According to researcher Cindy Ehlers, the first trait of the sleep-wake is a social Zeitstorer.  A social Zeitstorer is a person or social demand that throws a person’s sleeping patterns off balance.  For example, a social Zeitstorer may be a new relationship which alters the client’s patterns of sleeping and waking. 

A job that requires extensive travel can also be a social Zeitstorer. A social Zeitstorer can have significant debilitating effects on a bipolar client’s circadian rhythm, or the more biologically driven cycles such as when a client falls asleep, when he or she wakes up, or his or her pattern of rapid-eye movement during sleep. When these circadian rhythms are interrupted, a bipolar client is much more vulnerable to falling into a manic or depressive episode.

Lisa, a 36-year-old bipolar II client, lived with her husband Gerry.  During a therapy session with the couple, Lisa complained that Gerry had changed the schedule for feeding their two cats.  He had begun to feed them both in the morning instead of the evening, and as a result one or both of the cats were coming into the couple’s room in the middle of the night crying for food.  Lisa wanted to feed the cats before she and Gerry went to bed, but he refused, saying it would make the cats overweight. 

After three consecutive nights of poor sleep, Lisa became irritable, experienced mental confusion at work, and developed racing thoughts.  Finally, Gerry agreed to the new evening feeding schedule, which alleviated the problem with the cats. As Lisa returned to a regular sleep-wake cycle and experienced several nights of restorative sleep, her hypomania started to recede.  As you can see, the cats’ feeding schedule had become a social Zeitstorer, which interrupted Lisa’s circadian rhythm and almost sent her into full fledged mania.  The return to normalcy is what I like to call, "substituting a social Zeitgeber."

♦ 2. Social Zeitgebers
A social Zeitgeber, the second trait of the sleep-wake cycle, is quite the opposite of a social Zeitstorer.  Social Zeitgebers are people or events that function as an external time clock to regulate a client’s habits.  A spouse or even a dog that needs to be regularly walked can be considered a social Zeitgeber.  Social Zeitgebers affect sleeping and eating habits in a stable manner, keeping the balance of everyday activities. 

A bipolar client with several stable social Zeitgebers will be less likely to slip into a manic or depressive episode because their sleep patterns are regulated. Shawn, age 26 and a bipolar II client, had just been reassigned to a position in his company that required him to travel all over the world to attend business meetings.  Although Shawn was ecstatic about the opportunity to travel, it soon became apparent that the inevitable jet lag he underwent interrupted his circadian.  Shawn slipped into a manic episode, sleeping about three to four hours a night for near to a month. 

Very quickly, Shawn began to show visible signs of extreme fatigue and was admitted to a hospital in London for exhaustion.  Due to the danger that the new position posed for his health, Shawn opted for a job that remained in one city, which he was fortunately granted.  For those bipolar clients suffering from social Zeitstorers, like Lisa and Shawn, I recommend stabilizing their schedules or, "substituting a social Zeitgeber".  For Lisa, the Zeitgeber was feeding the cats in the evening while Shawn’s Zeitgeber was a position on the ground and in the same country.

♦ 3. Regulated Sleep Patterns - 7 Tips for a Good Night's Rest
In addition to social Zeitstorers and Zeitgebers, a third trait of the sleep-wake cycle is a regular sleep pattern.  Although this may sound simple, for those with bipolar disorder, it is essential to avoiding a manic or depressive episode. To do this, I give all my bipolar clients a list of "Tips for a Good Night’s Rest" and ask them to follow it religiously. I also recommend formulating these habits to try to get about 10 hours of sleep a night:
1. Establish a regular bedtime and stick to it as much as possible.  Avoid naps, but if you find it necessary, limit them to about twenty minutes as continuous sleep is much more restful.
2. If you use caffeine, limit your consumption to early in the day.  If you smoke or drink alcohol, stop doing so within a few hours of bedtime.
3. Let yourself unwind an hour or so before bedtime.  Read a book or magazine, listen to music, meditate, play with a pet, or take a bubble bath. Avoid violent TV shows, and skip upsetting news reports.
4. Save the bedroom for sleeping and sex.  Although light reading may be okay, don’t bring work to bed.  And save discussions for another place and time.  This includes conversations about sexual problems.  If you begin to associate work or arguments with your bed, it will cause more anxiety than it is worth.
5. Don’t try to force yourself to sleep.  Just enjoy resting and feeling your muscles.  Or use a relaxation technique, such as the ones found on sections 3 and 4.  Some people find listening to tapes or peaceful sounds helpful.
6. Adjust your sleep in advance when traveling to a different time zone. For very short trips, this may not be necessary, but for longer ones, adjust your sleep, meals, and medication dosage time to match the target time zone over several days.
7. Block out annoying distractions.  If light noise keeps you awake and you can’t block them out in other ways, cover your eyes with a black sleeping mask and wear ear plugs.
By following these simple guidelines, bipolar clients can more easily get a restful night’s sleep.

In this section, we discussed the traits of the sleep-wake cycle and how it affects bipolar clients:  social Zeitstorers, social Zeitgebers, and a regulated sleep pattern

In the next section, we will examine the differences found between men and women with bipolar disorder.  We will examine differences in suicide rate, effect of PMS on bipolar and unipolar women, and mania in men.
Reviewed 2023

Peer-Reviewed Journal Article References:
Brand, S., Gerber, M., Pühse, U., & Holsboer-Trachsler, E. (2010). Depression, hypomania, and dysfunctional sleep-related cognitions as mediators between stress and insomnia: The best advice is not always found on the pillow! International Journal of Stress Management, 17(2), 114–134.

Huhn, A. S., & Finan, P. H. (2021). Sleep disturbance as a therapeutic target to improve opioid use disorder treatment. Experimental and Clinical Psychopharmacology. 

Johnson, S. L., Tharp, J. A., Peckham, A. D., & McMaster, K. J. (2016). Emotion in bipolar I disorder: Implications for functional and symptom outcomes. Journal of Abnormal Psychology, 125(1), 40–52.

Miller, K. E., Davis, J. L., & Rhudy, J. L. (2018). Pilot study: Brief posttrauma nightmare treatment for persons with bipolar disorder. Dreaming, 28(2), 150–161. 

Raduga, M. (2021). Optimal sleep duration and its deviation outcomes from perspectives of REM sleep dissociative phenomena. Dreaming, 31(3), 244–251.

Schwartz, L. A., & Feeny, N. C. (2007). The nature of and behavioral treatment of sleep problems in youth with bipolar disorder. International Journal of Behavioral Consultation and Therapy, 3(1), 88–95.

QUESTION 6
What are three characteristics of the sleep-wake cycle? To select and enter your answer go to Test.

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