Embed Size (px)
Citation preview
Ac#grafiebijbipolairestoornisHetmetenvanac*viteit,slaapenstemming
StefanKnapen,MD/PhD-studentRixtRiemersma,psychiater
UMCG/UCP
Disclosurebelangenverstrengeling
• Geendisclosurestemelden
Inhoud
• Debiologischeklok
• Deklokendebipolairestoornis
• Longitudinalestudienaarrela#eslaap-waakritmeenstemmingsbeloop
Hetcircadianeritme
Lichtenhetbiologischeritme
“Two-processmodelofsleepregula#on”
Bipolairestoornis
Harvey,2008
Slaapproblemen–Tussenepisodes
Gemeten:• Meerverschilleninslaapduur• Vakerwelofnietwakkerworden‘snachts
Zelf-gerapporteerd:• Langerwakkerliggen• Langerslapen• Meerveranderingentussendezematen
Millar,2004
Ritmeveranderingen
• Meervariabelbinnendedag• Minderstabieltussendagen
Jones,2005
Ritmeveranderingen
IV=intradailyvariability IS=interdailystability
BiGstudie-DutchBipolarCohort(DBC)Contents lists available at ScienceDirect
Journal of Affective Disorders
journal homepage: www.elsevier.com/locate/jad
An actigraphy study investigating sleep in bipolar I patients, unaffectedsiblings and controls
Sanne Verkooijena,⁎, Annet H. van Bergena, Stefan E. Knapenb, Annabel Vreekera,c,d,Lucija Abramovica, Lucia Paganie, Yoon Jungg, Rixt Riemersma-van der Lekb,h,Robert A. Schoeversb, Joseph S. Takahashie,f, René S. Kahna, Marco P.M. Boksa,Roel A. Ophoffa,g
a Department of Psychiatry, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlandsb Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlandsc Netherlands Institute of Mental Health and Addiction (Trimbos Institute), Drug Information and Monitoring System, Department of Drug Monitoring,Utrecht, The Netherlandsd Department of Psychology, Leiden University, Leiden, The Netherlandse Department of Neuroscience, University of Texas Southwestern Medical Center, Dallas, TX, USAf Howard Hughes Medical Institute, University of Texas Southwestern Medical Center, Dallas, TX, USAg Center for Neurobehavioral Genetics, University of California Los Angeles, Los Angeles, CA, USAh Lentis FACT, Winschoten, The Netherlands
A R T I C L E I N F O
Keywords:Bipolar disorderActigraphySleep disturbances
A B S T R A C T
Objectives: Disturbances in sleep and waking patterns are highly prevalent during mood episodes in bipolardisorder. The question remains whether these disturbances persist during phases of euthymia and whether theyare heritable traits of bipolar disorder. The current study investigates objective sleep measures in a large sampleof bipolar I patients, non-affected siblings and controls.Methods: A total of 107 bipolar disorder I patients, 74 non-affected siblings, and 80 controls were included.Sleep was measured with actigraphy over the course of 14 days. Seven sleep parameters were analyzed for groupdifferences and their relationship with age at onset, number of episodes and psychotic symptoms using linearmixed model analysis to account for family dependencies.Results: Patients had a longer sleep duration and later time of sleep offset compared to the non-affectedsiblings but these differences were entirely attributable to differences in mood symptoms. We found nodifference between patients and controls or siblings and controls when the analyses were restricted to euthymicpatients. None of the bipolar illness characteristics were associated with sleep.Limitations: Medication use was not taken into account which may have influenced our findings and controlswere younger compared to non-affected siblings.Conclusions: In the largest study to date, our findings suggest that recovered bipolar I patients and theirsiblings do not experience clinically significant sleep disturbances. Sleep disturbances are primarily a reflectionof current mood state, but are unrelated to the course of the disorder.
1. Introduction
Bipolar disorder is a chronic psychiatric disorder characterized bysevere fluctuations in mood, which affects 1–2% of the generalpopulation (Belmaker, 2004). According to the DSM-V criteria, oneprominent manifestation of a mood episode is a shift in sleep-wakebehavior (American Psychiatric Association, 2013). The majority ofpatients experience insomnia or hypersomnia during depression and a
reduced need for sleep during mania (Harvey, 2008). These distur-bances are thought to be a hallmark of a current mood episode, andoften precede mood episodes, suggesting utility as a marker ofprodromal symptoms (Jackson et al., 2003).
Studies focusing on bipolar patients have tried to delineate whetherthese sleep disturbances can be considered as more than a state markerof the disorder and represent a general deregulation of the endogenouscircadian cycle independent from current episodes. In accordance with
http://dx.doi.org/10.1016/j.jad.2016.08.076Received 21 April 2016; Received in revised form 16 August 2016; Accepted 21 August 2016
⁎ Correspondence to: UMC Utrecht – Department of Psychiatry, Heidelberglaan 100 – Room A01.146, P.O. Box 85500, 3508 Utrecht, The Netherlands.E-mail address: [email protected] (S. Verkooijen).
Journal of Affective Disorders 208 (2017) 248–254
0165-0327/ © 2016 Elsevier B.V. All rights reserved.Available online 11 October 2016
crossmark
107pa#ënten74siblings80controles
Bevindingen:- Langereslaapduurenlateresleep-offset- Gerelateerdaanaanwezigheiddepressievesymptomen- Geenrela#emetkenmerkenziektebeloopm.u.v.
- Rela#eWASOensuïcidaliteit
VerschilleninIVenISwordenmomenteelgeanalyseerd
Slaapproblemenookmogelijkvoorspellend?
Jackson,2003
Langdurig:dagboeken
• Nachtvoorstemmingsveranderingminderslapen!
Bauer,2006
Langdurig:gemeten
Wehretal.,1979
Terugnaardekliniek
• PtD,36jm• BipolairestoornisI,sinds2003• Opname2003,19maanden• Maandaggoednieuws(goedesollicita#e,gezondheidgoed)
• 4nachtenweinigtotgeenslaap• Vrijdagpresenta#emetmanischeklachten
• Jeholteral*jdachteraan
Numetac#grafie
• PtH,40jv• BipolairestoornisI,aljarenlangbekendmee• Lifeevent
• Adequatereac#ept&behandelaar– 1mgLorazepam3nachten.
CASE REPORT
Coping with a life event in bipolar disorder:ambulatory measurement, signalling and earlytreatmentStefan E Knapen,1 Rixt F Riemersma-van der Lek,2 Bartholomeus C M Haarman,2
Robert A Schoevers1
▸ Additional material ispublished online only. To viewplease visit the journal online(http://dx.doi.org/10.1136/bcr-2016-216123)1Department of Psychiatry,University of Groningen,University Medical CenterGroningen, Research School ofBehavioural and CognitiveNeurosciences (BCN),Interdisciplinary Center forPsychopathology and Emotionregulation (ICPE), Groningen,The Netherlands2Department of Psychiatry,University of Groningen,University Medical CenterGroningen, Groningen,The Netherlands
Correspondence toStefan Erik Knapen,[email protected]
Accepted 27 September 2016
To cite: Knapen SE,Riemersma-van der Lek RF,Haarman BCM, et al. BMJCase Rep Published online:[please include Day MonthYear] doi:10.1136/bcr-2016-216123
SUMMARYDisruption of the biological rhythm in patients withbipolar disorder is a known risk factor for a switch inmood. This case study describes how modern techniquesusing ambulatory assessment of sleep parameters canhelp in signalling a mood switch and start earlytreatment. We studied a 40-year-old woman with bipolardisorder experiencing a life event while wearing anactigraph to measure sleep-wake parameters. The nightafter the life event the woman had sleep later andshorter sleep duration. Adequate response of both thewoman and the treating psychiatrist resulted in twonormal nights with the use of 1 mg lorazepam, possiblypreventing further mood disturbances. Ambulatoryassessment of the biological rhythm can function as anadd-on to regular signalling plans for prevention ofepisodes in patients with bipolar disorder. More researchshould be conducted to validate clinical applicability,proper protocols and to understand underlyingmechanisms.
BACKGROUNDModern techniques such as ambulatory assessmentof physiological parameters may be helpful tomonitor and signal potential elicitors of new epi-sodes in patients with a mental disorder. In bipolardisorder disruptions of the biorhythm such as achange in sleep are known risk factors for a switchin mood.1 We describe a case where ambulatorymeasurement could have functioned as a signal forearly treatment.
CASE PRESENTATIONA 40-year-old woman is in treatment for bipolardisorder type I since 8 years. The bipolar disorderwas diagnosed by a psychiatrist from the depart-ment of psychiatry of the University MedicalCenter Groningen according to the Diagnostic andStatistical Manual of Mental Disorders FourthEdition criteria. Since diagnosis and treatment shewas admitted once to the psychiatric departmentfor a depressive episode. She visited her treatingpsychiatrist around every 6 weeks. Furthermore sheexperienced subclinical mood swings once or twicea year, particularly after stressful life events. Thesesubclinical mood swings persisted after differentpsychological treatments (cognitive–behaviouraltherapy, interpersonal psychotherapy and individualconversations). She was treated with lithium,600 mg a day, with a blood level of 0.56 mmol/L,
after recent dosage lowering because of a develop-ing renal insufficiency, a known side effect oflithium treatment. As the renal insufficiency contin-ued after dosage decrease of lithium the patientswitched to lamotrigine as mood stabiliser. Thismedication change happened after the presentedevents.The patient participated in the study ‘Circadian
timing systems in bipolar disorder’ in theNetherlands from 15 July 2014 to 22 July 2014.2
The aim of the study was to identify variations incircadian rest-activity rhythms in-vivo. As part ofthe study she wore an actigraph (the Actiwatch 2,Philips Respironics, validated for sleep analysis), asmall wristband that can measure activity and lightand calculates sleep timing, duration and quality ofsleep.3 4 During the study the patient had noinsight in her own actigraphy data. During thisperiod she experienced a serious life event, the lossof a friend by an accident.The news of the loss came to her in the after-
noon. The following night she immediately had achange in her sleep pattern, went to bed ∼2 hourslater than usual and slept around 1.5 hours lessthan usual.
TREATMENTThe day after the life event, she contacted herpsychiatrist to discuss the event and its emotionalimpact, because she knew from earlier experiencethat this might destabilise her. The psychiatrist pre-scribed 1 mg lorazepam for two consecutive nights,knowing that sleep loss can provoke a moodepisode. Using lorazepam restored a stable rhythm,with regular in bed and out of bed times andhaving a night of about 7.5 hours.
OUTCOME AND FOLLOW-UPAfter two nights of lorazepam use, she slept at herregular time, going to bed at 23:14 and waking upat 8:10, without the use of lorazepam. Althoughshe was sad, her mood remained euthymicafterwards.See figure 1 for a visualisation of the rest-activity
rhythm in an actogram and online supplementaryinformation for average sleep time.
DISCUSSIONA major goal of bipolar disorder treatment is theprevention of manic or depressive episodes by early
Knapen SE, et al. BMJ Case Rep 2016. doi:10.1136/bcr-2016-216123 1
Novel diagnostic procedure
CASE REPORT
Coping with a life event in bipolar disorder:ambulatory measurement, signalling and earlytreatmentStefan E Knapen,1 Rixt F Riemersma-van der Lek,2 Bartholomeus C M Haarman,2
Robert A Schoevers1
▸ Additional material ispublished online only. To viewplease visit the journal online(http://dx.doi.org/10.1136/bcr-2016-216123)1Department of Psychiatry,University of Groningen,University Medical CenterGroningen, Research School ofBehavioural and CognitiveNeurosciences (BCN),Interdisciplinary Center forPsychopathology and Emotionregulation (ICPE), Groningen,The Netherlands2Department of Psychiatry,University of Groningen,University Medical CenterGroningen, Groningen,The Netherlands
Correspondence toStefan Erik Knapen,[email protected]
Accepted 27 September 2016
To cite: Knapen SE,Riemersma-van der Lek RF,Haarman BCM, et al. BMJCase Rep Published online:[please include Day MonthYear] doi:10.1136/bcr-2016-216123
SUMMARYDisruption of the biological rhythm in patients withbipolar disorder is a known risk factor for a switch inmood. This case study describes how modern techniquesusing ambulatory assessment of sleep parameters canhelp in signalling a mood switch and start earlytreatment. We studied a 40-year-old woman with bipolardisorder experiencing a life event while wearing anactigraph to measure sleep-wake parameters. The nightafter the life event the woman had sleep later andshorter sleep duration. Adequate response of both thewoman and the treating psychiatrist resulted in twonormal nights with the use of 1 mg lorazepam, possiblypreventing further mood disturbances. Ambulatoryassessment of the biological rhythm can function as anadd-on to regular signalling plans for prevention ofepisodes in patients with bipolar disorder. More researchshould be conducted to validate clinical applicability,proper protocols and to understand underlyingmechanisms.
BACKGROUNDModern techniques such as ambulatory assessmentof physiological parameters may be helpful tomonitor and signal potential elicitors of new epi-sodes in patients with a mental disorder. In bipolardisorder disruptions of the biorhythm such as achange in sleep are known risk factors for a switchin mood.1 We describe a case where ambulatorymeasurement could have functioned as a signal forearly treatment.
CASE PRESENTATIONA 40-year-old woman is in treatment for bipolardisorder type I since 8 years. The bipolar disorderwas diagnosed by a psychiatrist from the depart-ment of psychiatry of the University MedicalCenter Groningen according to the Diagnostic andStatistical Manual of Mental Disorders FourthEdition criteria. Since diagnosis and treatment shewas admitted once to the psychiatric departmentfor a depressive episode. She visited her treatingpsychiatrist around every 6 weeks. Furthermore sheexperienced subclinical mood swings once or twicea year, particularly after stressful life events. Thesesubclinical mood swings persisted after differentpsychological treatments (cognitive–behaviouraltherapy, interpersonal psychotherapy and individualconversations). She was treated with lithium,600 mg a day, with a blood level of 0.56 mmol/L,
after recent dosage lowering because of a develop-ing renal insufficiency, a known side effect oflithium treatment. As the renal insufficiency contin-ued after dosage decrease of lithium the patientswitched to lamotrigine as mood stabiliser. Thismedication change happened after the presentedevents.The patient participated in the study ‘Circadian
timing systems in bipolar disorder’ in theNetherlands from 15 July 2014 to 22 July 2014.2
The aim of the study was to identify variations incircadian rest-activity rhythms in-vivo. As part ofthe study she wore an actigraph (the Actiwatch 2,Philips Respironics, validated for sleep analysis), asmall wristband that can measure activity and lightand calculates sleep timing, duration and quality ofsleep.3 4 During the study the patient had noinsight in her own actigraphy data. During thisperiod she experienced a serious life event, the lossof a friend by an accident.The news of the loss came to her in the after-
noon. The following night she immediately had achange in her sleep pattern, went to bed ∼2 hourslater than usual and slept around 1.5 hours lessthan usual.
TREATMENTThe day after the life event, she contacted herpsychiatrist to discuss the event and its emotionalimpact, because she knew from earlier experiencethat this might destabilise her. The psychiatrist pre-scribed 1 mg lorazepam for two consecutive nights,knowing that sleep loss can provoke a moodepisode. Using lorazepam restored a stable rhythm,with regular in bed and out of bed times andhaving a night of about 7.5 hours.
OUTCOME AND FOLLOW-UPAfter two nights of lorazepam use, she slept at herregular time, going to bed at 23:14 and waking upat 8:10, without the use of lorazepam. Althoughshe was sad, her mood remained euthymicafterwards.See figure 1 for a visualisation of the rest-activity
rhythm in an actogram and online supplementaryinformation for average sleep time.
DISCUSSIONA major goal of bipolar disorder treatment is theprevention of manic or depressive episodes by early
Knapen SE, et al. BMJ Case Rep 2016. doi:10.1136/bcr-2016-216123 1
Novel diagnostic procedure
CASE REPORT
Coping with a life event in bipolar disorder:ambulatory measurement, signalling and earlytreatmentStefan E Knapen,1 Rixt F Riemersma-van der Lek,2 Bartholomeus C M Haarman,2
Robert A Schoevers1
▸ Additional material ispublished online only. To viewplease visit the journal online(http://dx.doi.org/10.1136/bcr-2016-216123)1Department of Psychiatry,University of Groningen,University Medical CenterGroningen, Research School ofBehavioural and CognitiveNeurosciences (BCN),Interdisciplinary Center forPsychopathology and Emotionregulation (ICPE), Groningen,The Netherlands2Department of Psychiatry,University of Groningen,University Medical CenterGroningen, Groningen,The Netherlands
Correspondence toStefan Erik Knapen,[email protected]
Accepted 27 September 2016
To cite: Knapen SE,Riemersma-van der Lek RF,Haarman BCM, et al. BMJCase Rep Published online:[please include Day MonthYear] doi:10.1136/bcr-2016-216123
SUMMARYDisruption of the biological rhythm in patients withbipolar disorder is a known risk factor for a switch inmood. This case study describes how modern techniquesusing ambulatory assessment of sleep parameters canhelp in signalling a mood switch and start earlytreatment. We studied a 40-year-old woman with bipolardisorder experiencing a life event while wearing anactigraph to measure sleep-wake parameters. The nightafter the life event the woman had sleep later andshorter sleep duration. Adequate response of both thewoman and the treating psychiatrist resulted in twonormal nights with the use of 1 mg lorazepam, possiblypreventing further mood disturbances. Ambulatoryassessment of the biological rhythm can function as anadd-on to regular signalling plans for prevention ofepisodes in patients with bipolar disorder. More researchshould be conducted to validate clinical applicability,proper protocols and to understand underlyingmechanisms.
BACKGROUNDModern techniques such as ambulatory assessmentof physiological parameters may be helpful tomonitor and signal potential elicitors of new epi-sodes in patients with a mental disorder. In bipolardisorder disruptions of the biorhythm such as achange in sleep are known risk factors for a switchin mood.1 We describe a case where ambulatorymeasurement could have functioned as a signal forearly treatment.
CASE PRESENTATIONA 40-year-old woman is in treatment for bipolardisorder type I since 8 years. The bipolar disorderwas diagnosed by a psychiatrist from the depart-ment of psychiatry of the University MedicalCenter Groningen according to the Diagnostic andStatistical Manual of Mental Disorders FourthEdition criteria. Since diagnosis and treatment shewas admitted once to the psychiatric departmentfor a depressive episode. She visited her treatingpsychiatrist around every 6 weeks. Furthermore sheexperienced subclinical mood swings once or twicea year, particularly after stressful life events. Thesesubclinical mood swings persisted after differentpsychological treatments (cognitive–behaviouraltherapy, interpersonal psychotherapy and individualconversations). She was treated with lithium,600 mg a day, with a blood level of 0.56 mmol/L,
after recent dosage lowering because of a develop-ing renal insufficiency, a known side effect oflithium treatment. As the renal insufficiency contin-ued after dosage decrease of lithium the patientswitched to lamotrigine as mood stabiliser. Thismedication change happened after the presentedevents.The patient participated in the study ‘Circadian
timing systems in bipolar disorder’ in theNetherlands from 15 July 2014 to 22 July 2014.2
The aim of the study was to identify variations incircadian rest-activity rhythms in-vivo. As part ofthe study she wore an actigraph (the Actiwatch 2,Philips Respironics, validated for sleep analysis), asmall wristband that can measure activity and lightand calculates sleep timing, duration and quality ofsleep.3 4 During the study the patient had noinsight in her own actigraphy data. During thisperiod she experienced a serious life event, the lossof a friend by an accident.The news of the loss came to her in the after-
noon. The following night she immediately had achange in her sleep pattern, went to bed ∼2 hourslater than usual and slept around 1.5 hours lessthan usual.
TREATMENTThe day after the life event, she contacted herpsychiatrist to discuss the event and its emotionalimpact, because she knew from earlier experiencethat this might destabilise her. The psychiatrist pre-scribed 1 mg lorazepam for two consecutive nights,knowing that sleep loss can provoke a moodepisode. Using lorazepam restored a stable rhythm,with regular in bed and out of bed times andhaving a night of about 7.5 hours.
OUTCOME AND FOLLOW-UPAfter two nights of lorazepam use, she slept at herregular time, going to bed at 23:14 and waking upat 8:10, without the use of lorazepam. Althoughshe was sad, her mood remained euthymicafterwards.See figure 1 for a visualisation of the rest-activity
rhythm in an actogram and online supplementaryinformation for average sleep time.
DISCUSSIONA major goal of bipolar disorder treatment is theprevention of manic or depressive episodes by early
Knapen SE, et al. BMJ Case Rep 2016. doi:10.1136/bcr-2016-216123 1
Novel diagnostic procedure
2016Knapen,SEetal.BMJCasereports
Studieprotocol
• 2x10pa#ëntenmetbipolairestoornistypeI• 180dagenac#grafie(slaapencircadiaanritme)endagelijkslifechartenstemmingsme#ng
Watvragenwevandedeelnemers:
• 5xbezoekaanUMCG• 1ebezoek:
– Demografie:Leeoijd,werk,gezondheidsvragenlijst,BMIwordtberekendenroken/drugsgebruikwordtuitgevraagd.
– MINI-diagnos#ek– MCTQMunichChronotypeQues#onnaire.– SPAQSeizoensgebondenstemmingsklachten
Watvragenwevandedeelnemers:
• WekelijksviaRoQua:– DeIDS– DeAltmanManiaRa#ngScale– SocialeRitmeMeter
Watvragenwevandedeelnemers:
• DagelijksviaRoQua:– Ochtend:Slaapdagboek
– Avond:Lifechart,socialeritmemeter
– Avond:VASvanstemmingskenmerken(standaardenindividueel)
Watvragenwevandedeelnemers:• 2ebezoekna2weken,controleofactometerwerkten
prak#schekantstudiebeloop
• 3een4ebezoekresp2en4maandennadestart
• 5ebezoek6maandennadestarttevenseindedeelname
Standvanzaken
• Eerste10deelnemers5maandenbezig– Geenuitval,heloheeostemmingsepisodedoorgemaakt
• Tweedegroepvan10deelnemersstartinapril
– Erzijnnogenkeleproefpersonennodig!– Inclusiecriterium:bipolaireIstoornis,1episodeinhetafgelopenjaar,gemo#veerdtotdagelijksestemmingsme#ng
