Carter Brandon

The Circadian and Social Rhythms of Bipolar Disorder

The role of circadian rhythms in mood disorders, particularly bipolar disorder (BD), is a

well-researched topic. Sleep disturbances are prevalent among the cast majority of persons with

BD across all stages of the illness and often act as a direct indicator of an upcoming mood

episode. Sleep plays a significant part in the onset and dysfunction of BD episodes. This research

paper reviews the relationship between sleep and BD, biological and psychosocial factors that

may influence the onset of episodes, and interventions to improve BD circadian and social

rhythms.

Insomnia, a hallmark symptom of mania or hypomania, is reported in 69%-99% of BD

patients (Gold & Sylvia, 2016). Even in euthymic, inter-episodic periods, insomnia-like sleep

patterns are reported in up to 70% of patients (Harvey et al., 2005). Biomarkers of mania include

“reduced REM latency, greater percentage of stage I sleep, increased REM density, discontinu-

ous sleep patterns, shortened total sleep time, and a greater time awake in bed.” (Gold & Sylvia,

2016). Not only does mania impact total sleep time, but also the overall quality of sleep. During

depressive episodes, 40%-80% report excessive sleepiness or hypersomnia. (Harvey et al.,

2015).

Naturally, these pervasive sleep patterns for people with the disorder create a wide vari-

ety of problems. Sleep disorders are often comorbid with other psychiatric disorders and un-

healthy behaviors (such as anxiety disorder, substance use disorders, obesity, and sedentary life-

styles). People with BD sleep less efficiently, which negatively affects energy levels during the

day and increases levels of anxiety and fear about not sleeping well (Harvey et al., 2005). Fur-

thermore, evidence suggests that sleep disturbance and daytime sleepiness (as a result of sleep is-
sues) may be predisposing factors for BD in vulnerable populations. Even in studies of healthy

populations, researchers have found a relationship between sleep disruption and cognitive dys-

function. Sleep deprivation, in general, has been associated with a 40% decrease in the ability to

learn new material (Yoo et al., 2015). As mentioned previously, up to 70% of individuals in the

inter-episode phase of BD—meaning they are not currently depressed or (hypo)manic, thus more

closely resembling a healthy population—report significant problems with sleep (Harvey et al.,

2005). An interesting 2017 study by J.C. Kanady et al. examined the impact of insomnia-related

sleep disruptions on working memory and verbal learning performance during inter-episode

bipolar disorder. The study’s results indicated that the amount of variance in sleep time in a

given week predicts poorer working memory and verbal language skills, regardless of insomnia

diagnosis. This suggests that the sleep disruptions commonly reported during the inter-episode

phase of bipolar disorder—specifically, the inconsistent total sleep times—may predict lower

cognition levels in many individuals with BD. A different recent study on the relationship be-

tween sleep quality and quality of life found that 41% of patients with bipolar 1 reported low

sleep quality. In comparison, 54% reported a low quality of life (Shamsaei & Sadeghi, 2020).

This low quality of life presents itself through poor physical health, reduced or restricted social

interactions, psychosocial stress, occupational instability, and a lack of medication adherence.

Sleep disturbances are also linked to an increased risk of suicidal ideation and attempts in pa-

tients with BD (Lai et al., 2013)—which is of particular concern as approximately 1 in 5 people

with BD complete suicide.

The amount, consistency, and quality of sleep significantly impact people’s lives. Which

presents the question: why do those with bipolar disorder experience difficulty sleeping? Most

research on the subject strongly indicates biological and psychosocial factors which interact and
influence each other. The natural sleep cycle of life involves the process of circadian rhythms

(regulated through the suprachiasmatic nucleus—a fascinating yet too-descriptive-for-this-paper

process which, affectionately, is referred to as the “master clock”) (Gold & Kinrys, 2019). Our

internal clock is entrained by synchronizing environmental cues known as zeitgebers—which

provide us with the necessary amount of stimulation to produce the 24-hour light/dark cycles in-

herent in most life. Examples of common zeitgebers include light exposure, eating schedules, so-

cial interactions, and physical activity (Gold & Sylvia, 2016). Unfortunately, people with BD

have weakly entrained circadian rhythms; life events and the stress associated with their occur-

rence disrupt daily social rhythms—or social zeitgebers (Boland et al., 2016). Life events that

cause social disruption are commonly associated with the onset of mania and hypomania

(Malkoff-Schwartz et al., 1998). Sleep disturbances in BD reduce energy levels, which decreases

the likelihood of engaging in social zeitgebers and other healthy behaviors (exercise, grocery

shopping, meditation, etc.) (Gold & Sylvia, 2016).

Other studies show relationships between the circadian system and reward systems, indi-

cating that BD individuals may have a hypersensitive Behavior Approach System (BAS)—char-

acterized by heightened responsiveness to reward-relevant stimuli (Boland et al., 2016). Stimuli

such as goals, achievements, and challenges are thought to “activate” the BAS and initiate spe-

cific behavioral and cognitive responses (e.g., excitement, goal-striving, focus, etc.); on the other

hand, the BAS becomes “deactivated” by stimuli such as failure or rejection, resulting in an in-

verse response [concerning activation-response] (Boland et al., 2016). In people with BD, the

(de)activation of the BAS disrupts social zeitgebers (bedtimes, mealtimes, work schedules), con-

sequently disrupting their circadian rhythms, drastically increasing the likelihood and severity of

a mood episode.
 Abnormal regulation of hormones in individuals with BD may provide additional biologi-

cal explanations for sleep disturbances. During bipolar I mania, some research discovered an in-

crease in melatonin—a hormone that plays a significant role in sleep, increasing at dark and de-

creasing during the day; conversely, melatonin decreased during depressive episodes (Gold &

Kinrys, 2019). Similarly, norepinephrine—a neurotransmitter and hormone which plays a role in

sleep-wake cycles, mood regulation, memory, etc.—may also function abnormally in BD pa-

tients; some studies show increased activity during mania and decreased levels during depressive

episodes (Gold & Kinrys, 2019). Sleep deprivation also involves the loss of top-down inhibitory

control usually exerted by the medial prefrontal cortex on the amygdala, creating a dysfunctional

mood regulation (Harvey et al., 2015). One fascinating study even found a relationship between

bipolar mood cycles and lunar tides. In this study, 18 patients’ manic-depressive mood cycles

synchronized with the biweekly tide surges of the moon; in one patient, their circadian rhythm

(and subsequent mood cycles) became entrained to “24.8-[hour] recurrences of every second

12.4-[hour] tidal cycle.” (Wehr, 2018). (Note: of course, more research is needed to support this

study’s claims, but it presents an exciting hypothesis, nonetheless).

Fortunately, several promising interventions aim to improve BD circadian rhythms—

most of which focus on the regulation of the above-mentioned social zeitgebers and rhythms.

Some relevant therapies include cognitive behavioral therapy for insomnia (and bipolar) (CBT-I

and CBTI-BP, respectively) (Gold & Kinrys, 2019), psychoeducation light and darkness thera-

pies (Gold & Kinrys, 2019), family-focused therapy (FFT), and interpersonal and social rhythm

therapy (IPSRT). For the sake of brevity, this paper will focus exclusively on IPSRT.

Developed in 2005 by Ellen Frank at the University of Pittsburgh, IPSRT incorporates

social rhythm theories into the structure of interpersonal psychotherapy and aims to “stabilize pa-
tients’ routines while simultaneously improving the quality of their interpersonal relationships

and their performance of key social roles.” (Frank et al., 2007). IPSRT emphasizes managing

mood symptoms by regulating social rhythms, medication adherence, and providing the neces-

sary skills to mitigate stressful life events (Steardo et al., 2020). The intervention also focuses on

four primary areas of interpersonal psychotherapy: unresolved grief, role transitions, role dis-

putes, and interpersonal deficits. Incorporating interpersonal therapy with social rhythm works

to alleviate the impact of stressful events on circadian cycles, hormone release patterns, and so-

cial zeitgebers (as mentioned above). As people with BD seem to possess a hypersensitivity to

arousal and stress, IPSRT works under the belief that even the reduction of minor interpersonal

and psychosocial stress can significantly reduce the likelihood of relapse (Frank et al., 2007).

The structure of interpersonal and social rhythm therapy splits into four phases.

The first phase is history-taking (usually three to five sessions), primarily about the patient’s ill-

ness and identifying their interpersonal deficits and social rhythm routines. An important part of

the initial phase is the use of the Social Rhythm Metric (SRM), which essentially works as a di-

ary that keeps track of when the patient goes and gets out of bed, eats, goes to work, when their

first social interaction occurs, etc. (Gold & Kinrys, 2019; Frank et al., 2007). The goal of the

SRM is to establish a regular routine, ideally reducing any variations to less than an hour. Once

these routines are established, the therapist and patient determine the interpersonal area they

agree needs immediate attention. The second phase (usually four sessions) focuses on reorganiz-

ing social rhythms and developing skills for interpersonal deficits and social stressors (Steardo et

al., 2020). The third phase (four sessions) focuses on building confidence in the patient’s learned

skills to help maintain their mood, level of functioning, and social rhythm regularity (Frank et

al., 2007). During this phase, the patient is encouraged to continue focusing on the quality of
their interpersonal relationships through several strategies: role-play, communication analysis,

decision analysis, etc. (Frank et al., 2007). The fourth phase (three to five sessions, reduced to

monthly) is a reevaluation and discussion of skills and advice as the patient moves forward with

their lives.

Studies on the efficacy of IPSRT have shown consistently encouraging results. One study

claimed that the “reduction of psychopathological burden remained stable after six months in the

experimental group.” (Steardo et al., 2020). Furthermore, researchers found that patients treated

with IPSRT plus pharmacotherapy reported improvements in anxiety and affective mood symp-

toms without adjusting their medications. One study randomly assigned unmedicated patients

with bipolar II (n = 92) to either weekly IPSRT plus quetiapine (brand name: Seroquel) or IP-

SRT with a placebo. IPSRT plus quetiapine resulted in more significant symptomatic improve-

ment. However, it also resulted in more side effects than IPSRT alone—including a statistically

significant increased risk for weight gain and reports of oversedation and dry mouth. (Swartz et

al., 2018). A subset of patients also did well with IPSRT plus placebo, suggesting the apparent

efficacy of IPSRT without medication as a reasonable treatment option (Swartz et al., 2018).

Other studies have used IPSRT in outpatient group settings with equally promising results. One

study of BD patients (n = 9) undergoing 12-16 IPSRT sessions of 90 minutes revealed substan-

tial improvement in depressive symptoms. However, the study did not find significant improve-

ment in manic symptoms (Steardo et al., 2020).

The evidence presented in this paper points toward an obvious but essential conclusion:

the sleep-wake cycle works as a vital mechanism for the cognitive, behavioral, and biological

functioning of the mind and body. Circadian rhythms drastically influence countless aspects of

daily life: energy levels, memory, hormone release, interpersonal relationships, occupational
functioning, goal-setting, quality of life, and mood—to name a few. The quality and amount of

sleep are building blocks to healthy functioning. Thus, it is imperative for vulnerable popula-

tions, particularly those with BD (and other more severe psychiatric conditions), to establish and

adhere to consistent sleep patterns. In conclusion, the goal of this paper is to remind everyone

to go to bed.
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