The Adverse Consequences of Sleep Disturbance in Pediatric Bipolar Disorder: Implications for Intervention

doi:10.1016/j.chc.2008.11.006

Child and Adolescent Psychiatric Clinics of North America

Volume 18, Issue 2, April 2009, Pages 321-338

https://doi.org/10.1016/j.chc.2008.11.006 Get rights and content

Bipolar disorder (BPD) is a severe and chronic disorder, ranked among the top 10 leading causes of disability worldwide. Bipolar spectrum disorders with onset in childhood and adolescence have a particularly severe course, including more suicide attempts and greater comorbidity. The evidence accrued to date indicates that sleep disturbances are common among youth with BPD. Moreover, sleep problems may be an early marker for BPD, a distinguishing feature of BPD, and a contributor to relapse. The evidence reviewed highlights that sleep problems are associated with a range of serious adverse consequences, including difficulty in regulating affect in the daytime and difficulties with cognitive functions, such as memory, learning, attention, and concentration. Evidence reviewed also points to sleep disturbance as one possible contributor to weight gain, comorbid substance use, and impulsivity. The implications for intervention are explored, and a multicomponent sleep intervention for youth with BPD is outlined.

Section snippets

Sleep in youth with bipolar disorder

Table 1 presents an overview of the studies that have reported the nature and extent of sleep disturbance in children and teenagers with bipolar disorder. Overall, the data suggest that sleep disturbance is a prominent feature of bipolar disorder in youth, although it is notable that only a handful of these studies were explicitly conducted to investigate sleep. Hence, much of our existing knowledge is derived from studies examining other aspects of the disorder in which sleep also happened to

Consequences of Sleep Disturbance for Youth with Bipolar Disorder

There are several lines of evidence indicating that sleep disturbances represent a critical issue for the functioning of youth with bipolar disorder. Moreover, data are beginning to emerge in support of the hypothesis that sleep disturbances may contribute mechanistically to the core pathophysiology of pediatric bipolar disorder—a little-studied but potentially very important line of investigation, which could inform early treatment approaches. Several aspects of the relationship between sleep

Current options and practices for treatment of sleep disturbance in children and adolescents (broadly, not focusing on bipolar disorder)

There is robust evidence for the use of a psychological intervention, cognitive behavior therapy (CBT), for treating adults with sleep disturbance.⁵⁸ The research literature on the treatment of sleep disturbance with psychological interventions in children and adolescents is small but promising as are the data on the behavioral and/or emotional improvements after the treatment of sleep problems in children and adolescents.59, 60, 61, 62 For example, Bootzin and colleagues⁶³ developed a

Current options and practices for treatment of sleep disturbance in adults with bipolar disorder

To the best of the author's knowledge, there are no clinical trials of interventions for sleep disturbance in adults with bipolar disorder (or in youth with bipolar disorder). However, several of the psychological adjunctive interventions for bipolar disorder include one or more components targeting sleep. Interpersonal and social rhythm therapy includes instruction in behavioral techniques designed to regularize routines and reduce social rhythm disruption.⁶⁶ CBT provides education about the

Toward a psychological intervention for sleep disturbance in youth with bipolar disorder

Given the prevalence of sleep disturbance among youth with bipolar disorder, the associated adverse consequences, and the lack of empirically tested treatments, a high priority for future research is to develop an intervention for the sleep disturbance experienced by youth with bipolar disorder. An intervention for sleep may be particularly acceptable to youth as the payoffs of improving sleep are immediate, and sleep is often perceived by patients to be an aspect of health that is free of the

Summary

Sleep disturbance in youth with bipolar disorder is critically important, yet surprisingly understudied. We have reviewed evidence on the prevalence and nature of sleep disturbance in youth with bipolar disorder. Evidence pointing to the importance of sleep includes that sleep disturbance appears to be an early marker for bipolar disorder; is a distinguishing feature of pediatric bipolar disorder; contributes to relapse, affect dysregulation, and deficits in cognitive functioning; and may also

Acknowledgments

The author gratefully acknowledges David Axelson, Natasha Dagys, Ron Dahl, Anda Gershon, Tina Goldstein, Steve Hinshaw, and Ben Mullin for helpful discussions relating to the content covered in this article.

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In this context, sleep studies, together with a greater understanding of the underlying neurophysiological substrate, could provide a theoretical framework to elucidate the etiopathogenesis of pediatric BD and to develop new strategies for the diagnosis and treatment of this condition (Harvey, 2009; Milhiet et al., 2011; Steiger and Kimura, 2010).
Bipolar disorder (BD) and attention deficit/hyperactivity disorder (ADHD) share numerous clinical features, which can make the differential diagnosis challenging. Studies conducted in adults suggest that patients with BD and ADHD have different sleep patterns. However, in pediatric populations, data on these potential differences are scant. The present preliminary study was conducted to identify potential differences in sleep alterations among youths diagnosed with BD or ADHD compared to healthy controls (HC). A total of 26 patients diagnosed with BD (n = 13) or ADHD (n = 13) were compared to 26 sex- and age-matched HC ([HC_BD], n = 13, and [HC_ADHD], n = 13). All participants underwent polysomnography. The mean duration of stage N2 sleep was shorter in the BD group than in controls (HC_BD). The BD group also had higher (non-significant) REM density (REMd) scores than controls while mean REMd scores were lower in the ADHD group versus controls. Compared to the ADHD group, the BD group presented a shorter N2 stage, a longer first REM sleep duration (R1), and greater REMd. According to our findings, these three variables—N2 stage, REMd, and R1—appear to differentiate patients with BD from those with ADHD and from HC.
Developmental pathways towards mood disorders in adult life: Is there a role for sleep disturbances?
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Growing evidence has been accumulated for mood disorders to arise in part from abnormal malfunction of the timing within and between the circadian system and human behaviour (for an overview see Harvey 2009; Harvey 2011; Wulff et al., 2010; MClung 2013). The “circadian hypothesis of mood disorders” has suggested that there is disruption between endogenous rhythms controlled by de-synchronization of the body clock suprachiasmatic nuclei, the master biological clock of the hypothalamus and social zeitgebers such as personal relationships, caring responsibilities, work, travel, timing of outdoor activities, physical exercise or meals, which all have the potential to weaken the circadian internal phase regularity (for an overview see Foster and Wulff 2005; Harvey 2009; Harvey 2011; McClung 2013; Dallaspezia and Benedetti 2011). Rhythmic clock-controlled gene expression regulates multiple monoaminergic brain regions that control mood and motivated behaviors, stress and inflammatory systems, reward circuits, arousal and sleep by interacting with the homeostatic regulation of sleep and wake (Wulff et al., 2010; McClung 2013).
Mood disorders are among the most prevalent and serious mental disorders and rank high among to the leading global burdens of disease. The developmental psychopathology framework can offer a life course perspective on them thus providing a basis for early prevention and intervention. Sleep disturbances, are considered risk factors for mood disorders across childhood, adolescence and adulthood. Assuming that sleep disturbances may play a pivotal role in the pathogenesis of mood disorders from a life course point of view, we reviewed the data on developmental pathways towards mood disorders in adult life in relation to sleep disturbances.
From February 2017, a systematic search was conducted in PubMed, PsycINFO and Embase electronic databases for literature on developmental pathways to mood disorders in adult life in relation to sleep disturbances and to 1) pre-natal stress, 2) early brain developmental processes, and 3) temperaments, character and attachment style.
Eleven, 54 and 15 articles were respectively selected.
Experimental and clinical studies revealed that exposure to prenatal/early life stress results in sleep disturbances such as poor sleep and altered circadian regulation phases and may predict or even precipitate mood disorders in adulthood. Chronic sleep disruption may interfere with neuronal plasticity, connectivity and the developing brain thus contributing to the development of mood disorders. In addition sleep and circadian dysregulations have been shown to be related to those temperaments, character and attachment styles which are considered precursors of mood disorders. Sleep and circadian behaviours may serve as early targets regarding mood disorders.
Sleep in Children With Psychiatric Disorders
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Citation Excerpt :
Similar to adults, the role of circadian rhythm dysfunctions has been implicated in the pathophysiology of pediatric bipolar disorder in the form of significantly lower levels and later onset of melatonin secretion.31 Sleep disturbance is also considered as an early marker for the onset and progression of bipolar disorder in youth who have a family history of bipolar disorder32; moreover, the presence of continued sleep disturbance is thought to contribute to relapse of episodes.33 Sleep disturbances in youth with bipolar disorder is often characterized by increased sleep-onset latency, multiple nighttime awakenings, variable total sleep time (TST) duration, greater total time awake during these nighttime awakenings, and decreased need for sleep.34,35
Sleep disturbances are common in pediatric psychiatric disorders and constitute key elements in diagnostic symptomatology of various primary psychiatric disorders including bipolar disorder, depression, and anxiety disorder. Although sleep is not included in key defining criteria of some impairing illnesses such as obsessive-compulsive disorder and schizophrenia, these disorders present with a very high prevalence of sleep disturbances. The interaction between sleep and psychopathology is very complex with significant interrelationship in development, severity, and prognosis of psychiatric disorders and comorbid sleep disturbances. The research ranging from small intervention case series to large epidemiologic studies have demonstrated the role of specific sleep complaints in specific psychiatric diagnoses. However, the research using objective instruments such as polysomnography and actigraphy remains limited in youth with psychiatric disorders. The intervention studies using pharmaceutical treatment specifically focusing on sleep disturbances in psychiatric disorders are also sparse in the pediatric literature. Early identification of sleep disturbances and behavioral management using cognitive behavior therapy–based tools appear to be the most effective approach for treatment. The use of psychotropic medications such as selective serotonin reuptake inhibitors for the treatment of primary psychiatric disorder often alleviate the psychological barriers for sleep but may lead to emergence of other sleep issues such as restless leg syndrome. The safety and efficacy data of hypnotics for primary sleep disorders are limited in pediatrics and should be avoided or used with extreme caution in children with comorbid sleep and psychiatric problems.
Psychosocial interventions in the treatment of youth diagnosed or at high-risk for pediatric bipolar disorder: A review of the literature
2015, Revista de Psiquiatria y Salud Mental
El trastorno bipolar pediátrico (TBP) se ha convertido en un campo de investigación en el que los tratamientos psicosociales han proporcionado una gran cantidad de hallazgos empíricos en la última década. Abordamos esta cuestión a través de una revisión sistemática destinada a establecer su eficacia y viabilidad como terapias adyuvantes para los jóvenes con TBP o en alto riesgo de TBP. Se realizó una búsqueda exhaustiva en bases de datos entre 1990 y septiembre del 2014. En total, 33 estudios se relacionaron específicamente con el tema y 20 de ellos eran artículos originales. La evidencia muestra que tanto la «psicoeducación familiar» como la «terapia familiar para adolescentes» son tratamientos probablemente eficaces en el TBP. Del mismo modo, la «terapia cognitivo-conductual centrada en el niño y la familia» se puede caracterizar como un tratamiento en fase experimental. Las terapias restantes no obtienen suficiente apoyo empírico, ya sea por la presencia de hallazgos inconsistentes entre los distintos ensayos clínicos, ya por contar con datos únicamente provenientes de estudios de casos. Además, los resultados de los estudios sobre tratamientos psicosociales proporcionan resultados concluyentes en cuanto a la viabilidad y aceptabilidad de dichas terapias. Son necesarios ensayos clínicos controlados con muestras de mayor tamaño con el fin de disminuir las deficiencias metodológicas encontradas en una gran parte de los tratamientos descritos.
Pediatric bipolar disorder (PBD) has emerged as a research field in which psychosocial treatments have provided a plethora of empirical findings over the last decade. We addressed this issue through a systematic review aimed of establishing their effectiveness and feasibility as adjunctive therapies for youth with PBD or at high-risk for PBD. A comprehensive search of databases was performed between 1990 and September 2014. Overall, 33 studies were specifically related to the issue and 20 of them were original articles. Evidence suggests that both «multi-family psychoeducational psychotherapy» and «family-focused therapy» are possible effective treatments for PBD. Likewise, «child and family-focused cognitive-behavioral therapy» may be characterized as a treatment in its experimental phase. The remaining therapies fail to obtain enough empirical support due to inconsistent findings among clinical trials or data solely based on case reports. Studies of psychosocial treatments provide concluding results concerning their feasibility and acceptability. Larger sample sizes and more randomized controlled trials are mandatory for diminishing methodological shortcomings encountered in the treatments displayed.
The Complex Role of Sleep in Adolescent Depression
2012, Child and Adolescent Psychiatric Clinics of North America
MRI exploration of pineal volume in bipolar disorder
2011, Journal of Affective Disorders
Circadian rhythm instability and abnormalities of melatonin secretion are considered as trait markers of bipolar disorder. Melatonin is secreted by the pineal gland. We investigated pineal volume in patients with bipolar disorder, and expected to observe smaller than normal pineal glands in cases of bipolar disorder.
The primary outcome was the total pineal volume measured for each pineal gland with T1 MRI sequence. Twenty patients with bipolar I and II disorder and twenty controls were recruited. Pineal glands with large cysts (type 3) were excluded.
After exclusion of individuals with type 3 cysts, 32 subjects were analyzed for total pineal volume (16 patients with bipolar disorder and 16 controls). Total pineal volume did not differ significantly between patients (total pineal volume = 115+/−54.3 mm³) and controls (total pineal volume = 110+/−40.5 mm³).
Contrary to our hypothesis, no difference in total pineal volume between patients with bipolar disorder and healthy subjects was observed. These results indicate that the putative dysfunction of the pineal gland in bipolar disorder could be not directly related to an abnormal volume of the pineal gland.

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The Adverse Consequences of Sleep Disturbance in Pediatric Bipolar Disorder: Implications for Intervention

Section snippets

Sleep in youth with bipolar disorder

Consequences of Sleep Disturbance for Youth with Bipolar Disorder

Current options and practices for treatment of sleep disturbance in children and adolescents (broadly, not focusing on bipolar disorder)

Current options and practices for treatment of sleep disturbance in adults with bipolar disorder

Toward a psychological intervention for sleep disturbance in youth with bipolar disorder

Summary

Acknowledgments

J Psychiatr Res

Biol Psychiatry

J Affect Disord

J Affect Disord

J Am Acad Child Adolesc Psychiatry

Psychiatr Clin North Am

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Affect Disord

J Affect Disord

J Affect Disord

Psychiatry Res

Curr Biol

Biol Psychiatry

Biol Psychiatry

J Psychiatr Res

J Am Acad Child Adolesc Psychiatry

Drug Alcohol Depend

Biol Psychiatry

Journal of the American Academy of Child & Adolescent Psychiatry

Pediatr Clin North Am

Clin Psychol Rev

Biol Psychiatry

J Affect Disord

Biol Psychiatry

J Psychosom Res

Progress in Neuro-Psychopharmacology and Biological Psychiatry

Sleep Medicine Clinics

Sleep Medicine Reviews

The psychology of bipolar disorder

J Affect Disord

Biol Psychiatry

Psychiatry Res

J Affect Disord

Clin Psychol Rev

Behav Res Ther

Clinical course of children and adolescents with bipolar spectrum disorders

Arch Gen Psychiatry

Two-year prospective follow-up of children with a prepubertal and early adolescent bipolar disorder phenotype

Am J Psychiatry

Bipolar disorder in childhood and early adolescence

Epidemiology of bipolar disorder

Admixture analysis of age at onset in bipolar I affective disorder

Arch Gen Psychiatry

Bipolar affective disorder in adolescence: a 10-year study

Aust N Z J Psychiatry

Phenomenology of children and adolescents with bipolar spectrum disorders

Arch Gen Psychiatry

The pharmacological treatment of child and adolescent bipolar disorder

Multifamily psychoeducation groups (MFPG) in the treatment of children with mood disorders

J Marital Fam Ther

The psychopathology and treatment of bipolar disorder

Annual Review of Clinical Psychology

Sleep and circadian rhythms in children and adolescents with bipolar disorder

Dev Psychopathol

Early detection of bipolar disorder: a pilot familial high-risk study of parents with bipolar disorder and their adolescent children

Bipolar Disord