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Mental Illness and Sleep Disorders

The National Institute of Mental Health estimates that one in five Americans have some sort of mental illness. The severity and duration can vary widely, and it is a much smaller percentage that is under medical treatment.

Sleep disorders are potential symptoms of almost every psychiatric illness. About 40 percent of patients who seek medical help for sleeping problems have a psychiatric condition. Meanwhile, to have a mental health disorder without sleep problems is quite rare: fewer than 20 percent of mental health patients don’t have sleep problems.

To an extent, sleep quality can be a barometer of mental health. For this reason, psychiatrists always inquire about sleep behavior when making a diagnosis.

Sleep disorders often coexist with anxiety and panic disorders, depression, ADHD, schizophrenia, eating disorders, substance use disorder, OCD, personality disorders, and bipolar disorder. Problematically, the sleep issues associated with these mental health disorders make it more challenging to manage symptoms and experience the benefits of treatment.

The Relationship Between Mental Illness and Sleep

Poor sleep is both a symptom and a cause of mental illness. Sleep problems may contribute to the development or prolongation of mental illness by making it more difficult to cope with mental problems.

Sleep disorders are comorbid with many other illnesses; the most common comorbidities with insomnia are mental illnesses. It’s estimated that 40 percent of insomnia patients and over 45 percent of hypersomnia patients have a psychiatric condition. On the other hand, people without mental illness have substantially lower rates of insomnia. It’s a striking enough difference that nobody doubts the tie between sleep disorders and mental illness any more.

People with mental illness often report the sleep they do get is not restorative. They wake up still feeling tired, whether from waking frequently during the night, falling asleep too late, or waking too early. In fact, as we’ll go into in the sections below, many studies show that patients with mental health disorders experiences demonstrable changes to their sleep architecture. Often, the individual spends more time in the lighter, less restorative stages of sleep, and less time in the critically important deep and REM stages of sleep.

The following chart indicates the odds ratios for specific anxiety disorders associated with lifetime sleep disturbances (adapted from Breslau et al). GAD, generalized anxiety disorder; OCD, obsessive-compulsive disorder.

Insomnia alone Hypersomnia alone Both
GAD 7.0 (2.8-17.2) 7.0 (2.8-17.2) 4.8 (1.5-15.2)
Panic Disorder 5.3 (2.0-13.6) 4.3 (1.3-14.8) 8.5 (3.1-23.5)
OCD 5.4 (2.0-14.8) 1.2 (0.1-9.7) 13.1 (48-35.7)
Phobic disorder 1.5 (1.0-2.3) 29 (1.8-4.8) 4.0 (2.5-6.5)
Any Anxiety Disorder 24 (1.6-3.5) 3.3 (2.0-5.4) 4.5 (2.8-7.3)

Insomniacs on the whole tend to suffer from this problem – getting less sleep overall and spending insufficient time in the deeper parts of sleep. This is what makes the disorder so particularly frustrating: they feel like there is no relief from their discomfort.

This lack of sleep in turn makes it more challenging to cope with the symptoms of their mental illness. The REM stage of sleep provides us with the emotional and cognitive benefits of sleep. With sufficient REM sleep, we feel emotionally balanced, and able to regulate our emotions and make good judgments. Our brain works and processes information as it should. Without it, we’re moodier, prone to irrationality and poor decision-making, and have difficulty remembering things. It’s easy to see how this mindset makes it tough to cope with mental health.

Together, mental illness and insomnia exacerbate the effects of each other, creating a classic negative feedback loop, and once they get started, push the patient in a downward spiral. This makes treatment of both conditions difficult.

Left untreated, the sleep problems associated with mental health disorders can be particularly dangerous. A University of Michigan study found a strong correlation between insomnia and suicide.

In the following sections, we’ll review the sleep disorders commonly associated with different mental health conditions.

Anxiety Disorders

Nearly one in five Americans suffers from some sort of anxiety disorder, such as generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder (OCD), phobia, post-traumatic stress disorder (PTSD), or panic disorder.

Sleep Problems Associated with Anxiety Disorders

Anxiety results from a reaction to stress. Big or small, stress of all kinds affect the nervous system. Individuals with an anxiety disorder, however, experience stress at a more acute level. It may stem from obsessive anxious thoughts, or they may be coping with PTSD from a trauma. Regardless of the cause of their stress, their nervous system does not “reset” back to normal as it does for those without an anxiety disorder.

This heightened state of anxiety keeps their nervous system constantly alert, in direct opposition to the sort of relaxation necessary for falling asleep. This experience occurs even at the hormonal level. Cortisol, the body’s stress hormone, operates in inverse to melatonin, the hormone responsible for inducing sleep. With more stress in our system, the tougher it is for our brain to produce adequate amounts of melatonin.

People with anxiety disorders may be prone to the following sleep problems:

  • Insomnia, which describes difficulty falling or staying asleep. Many individuals with anxiety disorder suffer from all-consuming anxious thoughts, anticipatory anxiety toward potential phobia triggers, or sense of feeling generally overwhelmed. This level of anxiety makes it difficult to relax the mind before sleep.
  • Hypersomnia, defined as oversleeping. Individuals may find themselves oversleeping as a response to the stress or exhaustion from insomnia. Insomnia and hypersomnia frequently occur together in many cases of anxiety disorders.
  • Nightmares are a common symptom of PTSD, where the individual relives the trauma during an intensely vivid dream.
  • Nocturnal panic attacks are experienced by 44 to 71 percent of patients with panic disorder. These share symptoms with daytime panic attacks, except that they occur during non-REM sleep. The individual wakes up feeling extreme panic or fear, perhaps accompanied by sweats, pains in the chest, and increased heart rate.

Treatment

Psychotherapy, particular cognitive behavioral therapy (CBT), is one of the most effective treatments for individuals experiencing sleep problems related to their anxiety disorder.

CBT is often recommended for anxiety disorders. CBT-I, the specialization devoted to insomnia, applies the same principles the patient is already familiar with from regular CBT, such as reframing their negative thoughts, to sleep. Therapists work with patients to educate them about healthy sleep habits, help them recognize the thoughts and behaviors interfering with their sleep, and learn how to replace them with healthier reactions.

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Depression

About 16 million adults have major depression. The negative affect, loss of interest in formerly enjoyable activities, suicidal ideation, and other symptoms severely impact their quality of life.

Sleep problems associated with depression

Insomnia affects 75 percent of individuals with depression, and it’s a major risk factor for suicide among this population. One study found that individuals with insomnia are 6 times more likely to develop major depression, and those with depression and comorbid insomnia are more likely to stay depressed.

Depressed individuals are more likely to spend a longer time falling asleep, spend less time asleep overall, experience disturbed sleep, and spend less time in REM sleep (as evidenced in the chart below):

rem sleep and depression

Even when the mood change isn’t enough to merit depression, insomnia is associated with sadness. Researchers have followed groups of insomnias in longitudinal studies that stretch over years. They consistently find having insomnia increases the risk of later development of mental illness.

Women with depression are more likely to experience sleep problems. Individuals with seasonal affective disorder (SAD), a seasonal form of depression, will experience different sleep problems to varying extents during different seasons of the year.

In addition to insomnia, individuals with depression may be prone to the following sleep problems:

  • Hypersomnia, or oversleeping, affects 40% of young adults and 10 percent of older adults with depression.
  • Obstructive sleep apnea (OSA) is also highly correlated with depression. Individuals with sleep apnea are over 5 times more likely to have major depression. OSA is a sleep-related breathing disorder where the individual stops breathing momentarily during sleep, lowering their blood oxygen levels and disrupting their sleep.

Treatment

Unfortunately, many of the antidepressants prescribed to treat depression can cause or worsen insomnia. That increased insomnia can make them more depressed.

Antidepressant medications are often used to treat insomnia. Amitriptyline, trazodone, or mirtazapine are known as sedating antidepressants, and the more common SSRI drugs in use today are employed for patients with sleep disorders, too. Some patients react to antidepressant medication by becoming more active and energetic, making it more difficult to initially fall asleep, even as the relief of the depression alleviates other aspects of their insomnia, such as their ability to stay asleep.

Often treating the depression makes the insomnia go away. This is particularly true in cases of mild depression (dysthymia) which is very common, and often results in troubled sleep. Many people find their insomnia disappears quickly when they start taking antidepressant medication.

Similar to anxiety disorders, CBT is effective for treating both depression and insomnia. The principles of CBT can be applied to reframing negative thoughts that contribute to depression and poor sleep.

Light therapy is another therapy that can help individuals with depression, especially those with seasonal affective disorder or hypersomnia. The therapy involves sitting in front of a specialized light device for a set period of time each day, in an effort to reset the individual’s circadian clock. Practicing light therapy in the morning helps wake up the individual for the day, while an early afternoon practice helps them stay awake and avoid falling asleep too early.

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Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a neurobiological disorder commonly diagnosed in childhood. It affects 5 percent of children and can persist into adulthood for many. The disorder is characterized by behavioral symptoms that predominantly fall into categories of inattentiveness, impulsivity, and hyperactivity.

Sleep Problems Associated with ADHD

The symptoms of ADHD, along with the medication used to treat it, result in fragmented sleep and potential sleep disorders.

People with ADHD are prone to the following sleep problems:

  • Insomnia affects up to 75 percent of people with ADHD. Some researchers believe this may be due to a delayed circadian rhythm (the individual naturally tires later in the day). In addition to difficulty falling asleep, individuals with ADHD may also wake frequently during the night.
  • Excessive daytime sleepiness is a common symptom of many sleep disorders. The individual is excessively tired during the day, to the extent that it interferes with their quality of life. Due to their sleep problems, individuals with ADHD are significantly more likely to be tired during the day, even if they get the same amount of sleep as their peers without ADHD.
  • Sleep apnea is also more common among people with ADHD. They can be twice as likely to display sleep-disordered breathing.
  • Periodic limb movement disorder (PLMD) and restless leg syndrome (RLS) are both more prevalent among children with ADHD.
    • PLMD describes a tendency to repeatedly kick or move the legs during non-REM sleep. Such movements prevent the body from fully resting and restoring itself during sleep.
    • RLS is a condition where the individual feels an uncomfortable tingling sensation, often when in a supine position. In order to find relief, they have to keep moving their legs. Understandably, this movement prevents them from falling asleep.

Treatment

The medications used to treat ADHD symptoms often result in sleep problems. Longer-acting ADHD medication tends to have stronger effects on sleep. It is important that individuals with ADHD inform their doctor about any sleep issues they’re experiencing, so those can be considered when developing a treatment plan.

CBT-I is a behavioral method recommended for treating the sleep problems experienced by those with ADHD. To calm the mind and body and counteract the hyperactivity symptoms of ADHD, therapists may particularly focus on progressive muscle relaxation and stimulus control techniques.

Other effective sleep therapies for individuals with ADHD include sleep restriction therapy, where therapists set a sleep schedule for their patient. Patients strictly follow this schedule, only spending time in bed during those hours, and not allowing for any naps or sleep time outside of it. Additionally, light therapy can help those with delayed circadian rhythms.

Sleeping with a weighted blanket can provide relief for those suffering from RLS symptoms. The general rule is to find a blanket that weighs 10 percent of your body weight, plus 1 pound.

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Schizophrenia

Schizophrenia affects 1 percent of Americans. This severe mental illness interferes with their ability to process reality, manage their emotions, and communicate with others. It’s accompanied by debilitating symptoms, such as hallucinations and psychosis.

Sleep Problems Associated with Schizophrenia

Between 30 to 80 percent of people with schizophrenia experience disturbed sleep.

Sleep problems common to schizophrenia include:

  • Abnormal or irregular sleep patterns. Individuals with schizophrenia don’t tend to sleep for one extended period overnight; instead, they are more prone to sleep at any point during the day or night. Based on their research of mice with defects in the SNAP25 gene (which is known to be linked to schizophrenia), scientists hypothesize the irregular sleep patterns are caused by a delayed melatonin release and shifted circadian rhythm. For individuals with schizophrenia, the delayed melatonin release continues pushing their sleep onset back later and later into the night, until eventually there is no clear circadian rhythm at all.
  • Inconsistent sleep volume. In addition to sleeping at irregular hours, people with schizophrenia generally tend to not get a regular amount of sleep on a day to day basis. At times they are prone to insomnia, and at others prone to hypersomnia. The side effects of their medication, or the symptoms of the disorder such as hallucinations, can cause either extreme. Because their sleep is so irregular, both in onset and in volume, their sleep quality also tends to be low. As a result, they’re less well-rested and prepared to cope with the symptoms of their disorder.

Treatment

The first generation of antipsychotics used to treat schizophrenia had no universal effect on sleep architecture, but the later generation of so-called atypical antipsychotics, including clozapine, olanzapine, and quetiapine, have observable positive effects on sleep. Schizophrenic patients who take them sleep longer. Some drugs increase the length of their slow-wave sleep, while some increase REM latency, similar to the effect of SSRI drugs on people with depression.

Treating the sleep issues does tend to alleviate the intensity of the psychotic symptoms of schizophrenia. However, clinicians advise adjusting the CBT-I strategies to account for the potentiality of triggering psychosis:

cbt-i for schizophrenia insomnia

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Personality Disorder

A personality disorder is defined as a way of thinking, feeling, or behaving that strays from the normal cultural expectation. Some common personality disorders are:

  • antisocial personality disorder
  • narcissistic personality disorder
  • avoidant personality disorder
  • paranoid personality disorder
  • borderline personality disorder

It’s estimated that about 1.6 percent of the U.S. adult population suffers from borderline personality disorder (BPD). BPD symptoms include unstable feelings in relationships that swing between intense feelings of love and hate, an unstable self image that impacts mood, chronic feelings of emptiness, and “out-of-body” feelings.

Sleep Problems Associated with Personality Disorders

Rates of substance abuse and depression are higher in those with personality disorders, causing studies that look at the relationship between sleep disorders and personality disorders confusing to interpret. Depression and substance abuse can negatively impact sleep, so the causation of the sleep disorder in those with personality disorders may be attributed to any of those factors.

Studies of personality disorder concurrent with sleep disorders are rare with most research focusing on BPD and sleep and antisocial personality disorder and sleep.

  • Insomnia is highly correlated with BPD and antisocial personality disorder. Symptoms including difficulty falling asleep, maintaining sleep, and waking up earlier than normal. This leads to complaints of daytime sleepiness and inability to function normally.
  • Shortened REM latency is seen in those with personality disorders. Shortened REM latency means the individual spends less time in restorative REM sleep. REM sleep is associated with cognition, memory, and mood stabilization. Shortened REM sleep may worsen the severity of a pre-existing personality disorder.
  • Nightmares and dream anxiety have been observed in people with BPD. Both of these have been attributed with lowering sleep quality and quantity.

Treatment

Cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) are the preferred methods for treatment of personality disorders. DBT focuses on teaching the patient new skills to deal with emotions and relationships. It includes four areas: mindfulness to accept the current mood, distress tolerance to tolerate negative emotions, emotional regulation to learn control, and interpersonal effectiveness to strengthen relationship skills.

Light therapy can improve well-being and circadian rhythms in those suffering from concurrent personality disorders and sleep disorders. Daytime alertness increased with light therapy as well.

CBT, DBT, and light therapy have shown positive associations with treating personality disorders and sleep disorders, which can often be comorbid.

Additional Resources

Eating Disorders

Almost 3 percent of U.S. adolescents aged 13 to 18 have been diagnosed with an eating disorder, and slightly over 1 percent of U.S. adults. Eating disorders disproportionately impact females. Eating disorders are serious and can be fatal illnesses that causes severe disturbances to a person’s eating behavior. Common eating disorders include binge eating disorder, bulimia nervosa, anorexia nervosa, and sleep-related eating disorder.

Sleep Problems Associated with Eating Disorders

Individuals with eating disorders frequently suffer from sleep problems. Some reports show half of those with an eating disorder also have a sleep disorder. Those with eating disorders may also suffer from depression, anxiety, or another mental illness. Sleep disorders in conjunction with mental health issues and eating disorders can become cyclical with one condition exacerbating the others. Weight loss, starvation, and malnutrition can all have a negative effect on sleep quality. Here are some common sleep problems in those with eating disorders:

  • Insomnia is especially prevalent in those with anorexia nervosa. Insomnia symptoms include having trouble falling asleep, waking throughout the night, and waking early in the morning, all of which lead to a reduction in total time spent asleep.
  • Circadian Rhythm sleep-wake disorder: Serotonin plays a large role in the circadian rhythm, when the brain tells the body it’s time for sleep. Eating disorders that cause malnutrition, starvation, or extreme weight loss can decrease the body’s supply of serotonin, throwing off the circadian rhythm. This causes the individual to have trouble falling asleep and waking up at a standard time.
  • Sleep apnea has strong links to weight, body-mass index, and eating habits. This sleep-related breathing disorder causes interruptions and cessation of breathing while sleeping, leading to fragmented sleep. Those with sleep-related eating disorder are especially prone to sleep apnea since the caloric intake in the night is high.
  • Excessive daytime sleepiness is a sleep disorder associated with insomnia, circadian rhythms disorders, and sleep apnea. As a result of poor sleep during the night, daytime alertness is decreased. This negatively impacts performance in work, daily activities, and social interaction. Excessive daytime sleepiness has been linked to further mental illness like depression. This could worsen the eating disorder.

Treatment

Treatment for an eating disorder often eliminates the sleep disorder. Cognitive behavior therapy (CBT) is the leading treatment for eating disorders. CBT for eating disorders includes retraining how the individual views food and realigns eating habits. CBT-E is an enhanced version of CBT that has shown success in those with eating disorders. The enhanced aspect aims to treat the underlying cause of an eating disorder such as low self esteem, perfectionism, or interpersonal difficulties. Both CBT and CBT-E have shown positive effect on alleviating eating disorders. With healthy eating habits, the sleep disorder is often treated without specific sleep-disorder therapy.

Bright light therapy has shown success in treating eating disorders, specifically bulimia and anorexia. Bright light therapy has also been successful in treating sleep disorders, so this option may treat both conditions simultaneously. This therapy involves sitting in front of a specialized light device which helps the body’s circadian rhythm function properly.

Additional Resources

Obsessive Compulsive Disorder

Obsessive compulsive disorder (OCD) is a disorder in which an individual feels uncontrollable recurring thoughts (obsessions) and behaviors (compulsions) accompanied by the urge to repeat the thought or behavior over and over. It’s estimated that 1.2 percent of adults in the U.S. suffer from OCD. The degree of OCD impairing an individual’s life range significantly from mild to severe. Approximately half of those with OCD have severe impairment. Common symptoms of obsessions include a fear of germs and contamination, or having things symmetrical or in perfect order. Common symptoms of compulsion include excessive hand washing or cleaning, repeatedly checking things, or counting. Symptoms of OCD may come and go.

Sleep Problems Associated with Obsessive Compulsive Disorder

  • Insomnia is common in those with OCD with up to 70 percent of sufferers reporting insomnia. OCD frequently includes feelings of danger, which is difficult to sleep with. One study found a significant link between insomnia and obsessions but found no link between insomnia and compulsions.
  • Delayed sleep-phase disorder are prevalent in those with OCD. More severe cases of OCD show a greater relationship with delayed sleep-phase disorder. In patients with OCD and delayed sleep-phase disorder sleeping occurs during irregular times that often don’t conform with normal society. Often they can’t wake up in time for work or school since bedtime is significantly delayed. Intrusive thoughts associated with OCD may make it difficult for an individual to quiet the mind to a calm state to facilitate sleep.

Treatment

Cognitive behavior therapy (CBT) is one of the first treatment options for those with OCD, as is common with other mental illnesses. Forms of CBT are also related to helping sleep disorders. Treating OCD with CBT may lessen the degree of sleep disruptions without direct treatment. If OCD symptoms are alleviated, sleep may concurrently improve.

Exposure Response Prevention Therapy (ERP therapy) is a type of CBT found especially effective in treatment for OCD. This therapy exposes the individual to what triggers the obsessions or compulsions and uses specific techniques to help overcome the desire to perform the obsessive or compulsive behavior. This is said to lower the anxiety level in those with OCD. A lowered anxiety level may also aid in better sleep.

Additional Resources

Substance Use Disorders

About 8 percent of the U.S. population over the age of 12 exhibits symptoms of a substance use disorder (SUD), over 21 million people. Over 44 million report illegal drug, non-medical use of a prescribed drug, or heavy alcohol use during the prior year. While that doesn’t qualify for a diagnosis of a SUD, some of these people may suffer from negative consequences of substance abuse, including sleep disorders induced by the substance.

In order of prevalence, these are the most common substances in substance use disorder diagnoses:

  • heavy alcohol drinking (binge drinking 5 or more times)
  • marijuana
  • opioids (heroin and prescription drugs)
  • sedatives/tranquilizers
  • stimulants, including methamphetamine
  • hallucinogens
  • cocaine

Sleep Problems Associated with Substance Use Disorders

  • Insomnia is the most common sleep problem associated with SUD. Insomnia with SUD presents itself as an inability to fall asleep, maintain sleep, and wake up at a normal hour for work or school. Despite the opportunity to sleep at normal times for an appropriate amount of time, those with SUD can’t maintain a healthy level of sleep. They often report sleep issues on three or more nights per week for over three months or more. This insomnia presents significant daytime functionality issues. Insomnia issues are reported up to one year after those with heavy alcohol consumption have abstained from drinking. This links alcohol withdrawal with insomnia symptoms. Sleep issues such as insomnia are sometimes attributed to relapses in recovery from substance use disorders.
  • Sleep apnea prevalence in higher in those with SUD related to alcohol consumption. One study indicated a 25 percent increase in sleep apnea in those who have high levels of alcohol consumption. Alcohol can relax the throat muscles, causing breathing obstruction. Those who don’t normally show symptoms of sleep apnea can experience the sleep disorder on nights when they’ve consumed alcohol.
  • Restless leg syndrome is observed in some cases of SUD mainly those that include opioid dependency. This association becomes especially pronounced when an individual is experiencing withdrawal symptoms of opioid addiction.

Treatment

Melatonin has positive results in treating insomnia in those with alcohol consumption SUD. Melatonin levels are low in alcohol-dependent patients. This treatment helps realign the circadian rhythm cycle.

Cognitive behavioral therapy (CBT) in conjunction with counseling is another treatment plan for those with SUD. This application of CBT focuses on the relationship between thoughts, actions, and behaviors that spur the substance use. Modifying those thinking patterns can help recover from the substance use disorder.

Sleeping disorders associated with SUD may be alleviated without specific therapy once the SUD is under control.

Additional Resources

Bipolar Disorder

Bipolar disorder affects nearly 3 percent of American adults. The most prevalent symptoms are wide swings in mood, behavior, and energy, accompanied by resulting swings in sleep and waking.

Sleep Problems Associated with Bipolar Disorder

The sleep issues a person with bipolar disorder experiences will change depending on whether they are in a state of mania or depression.

The most common sleep problems affecting individuals with bipolar disorder include:

  • Insomnia, or difficulty falling or stay asleep. Insomnia can occur during both mania or depression.
  • Sleeplessness is more common with episodes of mania. Distinct from insomnia, this describes the ability to go for long periods without sleeping, and without feeling a subjective need for sleep.
  • Hypersomnia, or oversleeping, is more common during episodes of depression.
  • Irregular sleep patterns are common, especially during episodes.
  • Delayed sleep phase syndrome (DSPS) describes a condition where the individual’s circadian rhythm is delayed. The person naturally tires at a later time than “normal,” so they fall asleep and wake up later, causing disruptions and tiredness during their daily routine as they adhere to the “normal” schedule of daily life. DSPS is like living in a constant state of jet lag.
  • Sleep apnea is significantly more common among individuals with bipolar disorder. The sleep-disordered breathing caused by sleep apnea disrupts their sleep, which can spark another manic episode or make it more difficult to cope during periods of depression.

Whether caused by or independent of bipolar disorder, the sleep problems these individuals experience make it more difficult to cope with the symptoms of the disorder. The highs and sleeplessness associated with mania catch up with the individual during the resulting depression stage, during they worsen the overall hopelessness they feel.

Meanwhile, lack of sleep prior to an episode of mania is one of the biggest warning signs that mania is about to occur. Even sleep deprivation from something as benign as jet lag can trigger an episode.

Even in between episodes, individuals with bipolar disorder also experience lower quality sleep. They have more difficulties falling asleep and experience more interruptions to their sleep.

Treatment

As with most cases of insomnia, research indicates CBT-I is an effective behavioral treatment for insomnia among individuals with bipolar disorder. Sleep restriction and stimulus control techniques in particular proved effective.

Additional Resources:

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