Curse or information? Unfortunately, a comorbid condition in bipolar disorder is sleep problems. You have probably found yourself lying with your eyes wide open, thoughts racing, ideas flooding your head, stress about what will happen if you don’t sleep again making it even harder to fall asleep… what to do?
In this post, I will present what science says about coping with insomnia, also in the context of bipolar disorder.
Example
For the past week, I had trouble sleeping; every other day I was sleep-deprived, and when I did sleep, the quality of that sleep was terrible. I went to bed stressed, afraid that I wouldn’t sleep a wink again. I took my medication at my usual time and read a book for two hours to calm myself down. When I decided to try to fall asleep, I dimmed the light slightly. I didn’t turn it off completely because when it’s dark, I feel forced to sleep, I feel pressure that stimulates me even more. Instead, I put on a sleep mask. I laid there… thoughts started to swirl, usually negative, I felt aversion to them, and I couldn’t fall asleep. Hunger struck, and I wandered into the kitchen for a snack (sometimes I even end up cooking at night). I felt guilty for keeping my husband awake. Did I do something wrong? Can I do anything about it at all?
The Problem
In bipolar disorder, sleep problems often occur. It’s not obvious, but these issues can often accompany BD [1]. There is often a tendency to engage in something at night that stimulates us even more and the inability to stop ourselves. Screen exposure, online shopping, major house cleaning, pacing around the house (to get tired). Time passes, and we feel down because we aren’t sleeping, and a difficult day lies ahead. We reproach ourselves for failing to fall asleep and fear that symptoms of mania may soon appear – or already have.
We try medication – propranolol, hydroxyzine, nasen, estazolam, and others. The strategy for taking these medications must be agreed upon with a doctor. Treating insomnia with medication is a delicate matter and a symptomatic approach. Doctors also always advise: do not sleep during the day, do not overexert yourself during the day (light activities only). Contrary to appearances, physical exhaustion will not make you sleep better; it will actually stimulate you even more.
The methods described above (medication) are more of a last resort – you are drowning and have no other solution. Sometimes it’s the only option, and you have to use it. But what if we take a step back and assess what contributed to our insomnia? It may seem like it just appears, but there are certainly periods when we are more vulnerable. But can we manage our day, week, month in such a way as to prevent insomnia?
Let’s go back to my example. What did I do? I took sleeping pills (not too much and not too often, but I did resort to them). I failed to resist napping during the day. And on the days I slept well, I resumed intense physical activity. As a result, I destabilized myself. I couldn’t accept that the illness would again intrude on my training plans and force me to abandon them. Is there a mistake in that thinking?
Sleep plays important regulatory functions for mental health; sleep disorders, and especially insomnia, can promote a state of allostatic overload (in other words, physiological wear and tear due to stress), which impairs brain neuroplasticity and stress-related immune pathways, thereby contributing to the development of mental disorders [2].
Like a boomerang
One of the two most proven methods for coping with insomnia is cognitive behavioral therapy [1]. This topic comes back again like a boomerang. The second method is pharmacological treatment. However, the downside of sleeping pills is that they are highly addictive, cannot be taken for too long, and do not provide long-term improvement.
CBT-I (Cognitive Behavioral Therapy for Insomnia) is based on working with thoughts, fears, stress, and also on changing sleep-related routines. This therapy consists of several elements: monitoring sleep rhythm – watches that track sleep and show statistics are helpful – relaxation methods (e.g., meditation, yoga), and general sleep hygiene.
Difficulties with arousal, intrusive thoughts disturbing sleep, heightened emotions, and ineffective efforts to fall asleep are very common in insomnia [1]. People who usually sleep well and fall asleep quickly have an association that going to bed in the evening means a reward in the form of sleep, while people who often experience insomnia associate the bed/bedroom with poor sleep, they do not look forward to sleep with joy but with fear. When I read this, I realized that I had completely deprived myself of the pleasure of falling asleep in my own bed; instead, I felt anxiety that I would sleep poorly and just wanted morning to come already. I wonder whether I will fall asleep or not.
Stimulus Control Therapy (SCT) is one of the most effective non-pharmacological methods of treating insomnia (from the cognitive behavioral therapy approach). The therapy presents several simple rules: do not go to bed if you cannot sleep, because if you lie in bed for hours without sleeping, the bed becomes associated precisely with not sleeping; do not force yourself to lie in bed if you are awake; instead, get up and do something calm in another room; wake up at the same time every day and do not use the snooze button.
A deeper approach to the problem
An interesting book points out five principles that are supposed to improve sleep [3]. The first principle says that one must realize how important sleep is for our functioning. One can live for a long time without food, but without sleep, much shorter. Sleep allows us to function, to live, to pursue our dreams, to meet people, to work, and to do other things we want to successfully accomplish. I only realized this when I became deeply involved in sports. I knew that every sleepless night meant skipping training and losing continuity. But I suspect that most people with bipolar disorder don’t have a problem here. Because we want to sleep; we want to live normally. Nevertheless, it is worth trying to sleep, making efforts to fall asleep, and using medication if recommended by a doctor. Personally, I feel the inability to fall asleep as a curse. This principle about the importance of sleep may also be a double-edged sword for some because it can cause guilt for not sleeping and anger at oneself, which then makes it even more difficult to sleep.
The second principle says to prioritize sleep, put it first. If this foundation fails, we cannot fully use our potential during the day. We limit ourselves if we do not take care of our basic needs. The other principles emphasize that we should personalize our needs regarding sleep and falling asleep, accept not sleeping, occupy ourselves with something if we cannot sleep, take an individual approach to this issue, and experiment.
Of course, there are a number of golden rules such as having a good mattress, lower temperature in the bedroom, avoiding caffeine in the afternoon, calming down one or two hours before bedtime, avoiding alcohol, or intense physical activity right before sleep – instead doing yoga or meditation, avoiding exposure to social media, games, avoiding reading the news or watching movies.
Sleep disorders often also take other forms, such as periodic limb movements during sleep (PLMD), which prevent falling asleep or reduce sleep quality.
Theory vs. implementation
This sounds rather strict and somewhat frightening, especially for people with BD. There is fear of developing mania from lack of sleep when we first impose these rules on ourselves. But haven’t you gone through harder things? – hospitals, starting new medications, changing medications, and of course depression and mania. It’s worth trying, taking the risk, disciplining yourself. It turns out that we cannot only focus on detecting and preventing mania or depression symptoms. We not only have to deal with mood swings but also take on another problem – insomnia – treating it as a separate task. Taking care of ourselves in both these areas gives synergistic benefits.
Is there anything else?
Recently, thanks to meditation, I have been discovering how incredibly powerful self-empathy and acceptance are. Such gentleness and self-care, meeting your needs rather than your “wants,” help in all processes related to overcoming difficulties in illness. This allows full use of behavioral techniques. Interestingly, the more you work on acceptance, the more you realize that you have too little of it toward yourself and that there is still so much to gain and that you can feel even more comfortable, safe, and calm. I write about this because it is key to accepting not sleeping and accepting the body’s needs and then taking (scientifically proven) actions that are good for us—for us meaning our body and mind. Self-empathy enables self-healing, self-care, avoiding overstrain, understanding one’s own needs—the needs of one’s (ill) body.
The good sleep manual
Finally, I would like to draw particular attention to the book “Pokonaj bezsenność w 6 krokach” [4] – only in Polish version for now. The insomnia treatment program is based mainly on cognitive behavioral therapy. The authors are scientists working in a sleep disorder treatment clinic and conducting insomnia therapy and training in this field. The book contains everything needed to deal with the problem of insomnia, along with research results and patient interviews. All the techniques presented are research-backed.
The therapy is divided into six steps undertaken sequentially over six weeks. In my case, I had trouble maintaining the daily recommendations, so I stretched it out a bit longer. After mastering one technique, I moved on to the next.
The first step recommends keeping a sleep diary, measuring values such as the time from lying down to deciding to try to sleep and then falling asleep, nighttime awakenings, and more. You only check the clock twice: when going to bed and when turning off the alarm in the morning. All other times are estimated subjectively. Thanks to the sleep diary, you can measure so-called sleep efficiency, i.e., how much of your time in bed you actually sleep. It may turn out that your body needs significantly less or significantly more sleep than you impose on it. This is the starting point – awareness of wasted time spent in bed and actual sleep needs. I started therapy with the book during severe sleep problems, and thanks to the techniques used, the situation improved significantly within three weeks.
The second step is ensuring sleep hygiene, which includes: regular sleep times; avoiding naps during the day (especially longer than 15 minutes and in the evening); coffee only in the morning and generally reduced caffeine intake (caffeine is also in tea or cocoa, and its half-life can be up to seven hours); reducing nicotine or quitting smoking (nicotine decreases deep sleep); limiting alcohol (it has sedative properties but worsens sleep quality in the second half of it); physical activity (e.g., one hour, four times a week, but at least four hours before bedtime); healthy eating and avoiding heavy meals within four hours of sleep; limiting “light exposure” (phones, screens, bright lamps, but thick curtains, and exposure to daylight during the day – to maintain natural circadian rhythm); limiting noise (earplugs); bedroom comfort (lower temperature, comfortable mattress), and relaxation before sleep (breathing exercises, meditation, light yoga, or another form of calming down).
In the third week, focus is recommended on maintaining fixed, personalized sleep schedule—waking up with an alarm without snooze. It’s worth thinking carefully, preferably testing, what time is optimal (if you can afford it). So-called “night owls” may have a serious problem with getting up early, so you can shift those times a bit. Sleep times are easiest to set using a sleep diary. After this week, I largely eliminated my sleep problems and abandoned therapy. However, that was not a good step because problems return, and the next, fourth step of therapy is extremely important.
Stimulus control is another technique in the following week of therapy. It mainly consists of arranging and maintaining one’s bedroom so that there are no stimuli that may disrupt sleep. In the bedroom, we do not read, watch, listen to music, turn on the overhead light, or eat. All these things are done outside the bedroom – in another room. The key is that the bedroom is only and exclusively for sleeping (and sex). If we feel the urge to browse social media, shop, or eat, we should move to another room. However, one should not then fall asleep in that room. Thanks to this approach, the bedroom will finally start to be associated with sleep, which will make falling asleep easier and reduce anxiety.
In the fifth step, therapy uses cognitive-behavioral techniques to the greatest extent, enabling work on intrusive thoughts that bother us while falling asleep. The therapy focuses on eliminating fears, working with automatic negative thoughts, and aversion. Thanks to the technique of writing down: the situation – the thought – the level of the emotion occurring with it – our reaction, it is possible to recognize, change thinking, and act appropriately when these unpleasant feelings repeat. The most common emotion is anxiety, which wakes us up to the extent that we completely lose the desire to sleep — “What if I don’t fall asleep again?”, and frustration — “Why do I have these problems, why do I have to suffer like this, can’t it be normal?”
In the last, sixth step, the authors of the book propose appropriate forms to fill out, which increase the patient’s awareness of the benefits of therapy, the consequences of abandoning learned techniques, and methods of preventing relapses.
The use of techniques from the book results in visible sleep improvement after just a few weeks. Knowing that these techniques produce such phenomenal effects, in the case of further insomnia problems, the level of anxiety related to the fear of what it will lead to again is much lower – because we already have a proven tool to use. Sleeping pills can be completely stopped (if the techniques work and the doctor supports such an approach). Personally, instead of sleeping pills, I sometimes take something to calm down (e.g., Propranolol), because I realized that anxiety is a secondary but main reason for my sleeplessness. However, if it is hyperactivity, sometimes I resort to sleeping pills, but this is 1–2 times a week during periods of serious sleep problems (while using therapy).
Summary – medication or therapy
I also learned not to panic, thanks to the skills of early mania detection (which I gained thanks to the techniques described in all my posts). If the amount of sleep is decent (in my case it is 4–5 hours) and this state does not last longer than a week, then constantly applying the techniques, I patiently wait for the effects. In my case, premature use of antipsychotic drugs such as olanzapine causes difficulties with withdrawal later, which itself is related to another BD swing. Regardless, whenever a doubt appears in the mind or when we are at an early stage of therapy, there is no point in waiting – it is best to communicate all our doubts to the doctor. For them, this is very important information about our “individual” illness and increases the likelihood that the situation will not get out of control.
– Agnieszka
*The information and comments in this post do not constitute medical advice. The author takes no responsibility for any use of them.
[1] Riemann D. et al. The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023. 2023
[2] Palagini, L., Hertenstein, E., Sleep, Nissein, C. Riemann, D., Nissen, C. Sleep, insomnia and mental health. 2022,
[3] Colin A.E. The ‘5 principles’ of good sleep health. 2021
[4] Fornal-Pawłowska M., Walacik-Ufnal E. Pokonaj bezsenność w 6 krokach z terapią poznawczo-behawioralną. 2020