Journal of Sleep Medicine and Disorders

CPAP Induced Manic Episode in a Patient with Bipolar Disorder: A Case Report of Central Sleep Apnea

Case Series | Open Access Volume 7 | Issue 2 |

  • 1. Department of Physiology, Medical School, Atatürk University, Turkey.
  • 2. Department of Psychiatry, Medical Park Y?ld?zl? Hospital, Turkey.
  • 3. Department of Neurology, Medical School, Atatürk University, Turkey.
  • 4. Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, I?d?r University, Turkey
  • 5. Department of Biochemistry, Regional Training and Research Hospital, University of Health Sciences, Turkey
  • 6. Department of Psychiatry, Private Alt?nkoza Hospital, Turkey.
  • 7. Department of Endocrinology and Metabolism, Medical School, Zonguldak Bülent Ecevit University, Turkey
+ Show More - Show Less
Corresponding Authors
Murat Kayabekir, MD, Ataturk University, Medical School, Department of Physiology, Telephone: +905327356836, Fax: +904423446528

Objective: In this case report we present our laboratory observations of one patient with bipolar disorder and central sleep apnea (CSA) who was treated with continuous positive airway pressure (CPAP) for their sleep apnea.

Background: Bipolar disorder is a psychiatric disorder characterized by episodes of mania, hypomania and major depression. This disorder affects approximately 0.8% of the adult population. Bipolar disorder frequently disrupts mood, energy, sleep, cognition, behavior and patients thus struggle to maintain employment and interpersonal relationships. Obstructive sleep apnea is a fully described and well-recognized entity. Central sleep apnea (CSA), however, has been poorly studied. The prevalence of obstructive sleep apnea (OSA) is expected to be high in bipolar disorder due to accompanying comorbid obesity. There is no evidence according to frequency of CSA in the patients with bipolar disorder. Coexistence of CSA and bipolar disorder has not been previously reported.

Results: The case of bipolar disorder, CPAP was started after a polysomnographic diagnosis of CSA and CPAP titration study indicating that most of the apneas/hypopneas were eliminated with a significant improvement in oxygen saturation. It was very remarkable that in this case initiation of CPAP resulted in manic symptoms and also symptoms of the REM behavior disorder.

Conclusions: Psychiatrists, especially laboratory physicians and other clinicians need to monitor patients with bipolar disorder closely for worsening of manic symptoms when they are started on CPAP for underlying mild OSA and especially severe CSA.


•    CSA
•    CPAP therapy
•    Manic symptoms
•    Bipolar 
•    REM behavior disorders


Kayabekir M, Eren F, Ceylan M, Bayraktutan ÖF, Alt?nkaynak K, et al. (2021) CPAP Induced Manic Episode in a Patient with Bipolar Disorder: A Case Report of Central Sleep Apnea. J Sleep Med Disord 7(2): 1125.


AHI: Apnea-Hypopnea Index, BD: Bipolar Disorder, CA: Central Apnea, CS: Cheyne Stokes breathing, CSA: Central Sleep Apnea, CSAS: Central Sleep Apnea Syndrome, CPAP: Continuous Positive Airway Pressure, OSA: Obstructive Sleep Apnea, PSG: Polysomnography, REM: Rapid Eye Movement, NREM: non-REM, SaO2: Arterial Oxyhemoglobin Saturation, W: Awake


Bipolar disorder (BD) is a psychiatric disorder characterized by episodes of mania, hypomania and major depression. BD is still being understood, in which genetic and environmental factors play a role. It is thought to be associated with circadian dysregulation. Mood exacerbations may also be provoked by seasonal patterns and alterations in light intensity (1-2). This disorder affects approximately 0.8% of the adult population. BD frequently disrupts mood, energy, sleep, cognition, behavior and patients thus struggle to maintain employment and interpersonal relationships (3). First-line treatments for BD include lithium and valproic acid supplemented by use of atypical antipsychotics, all of which are associated with myriad multisystem side effects, especially weight gain, that predispose patients to obstructive sleep apnea (OSA) among other potential complications (4). Sleep apnea: it is the stopping of respiration for 10 seconds or longer during sleep. The patient’s partner or close ones describe it as an interruption of snoring, as patient holding his/her breath during sleep. There are two main types of apnea: In central sleep apnea (CSA) air flow stops together with the effort of respiration. In OSA, air flow stops because of a narrowing in the upper respiratory tract but the effort of respiration still continues (5). OSA is mainly accompanied by snoring and other complaints like night sweats, feeling of suffocation, nocturia, morning headaches, irritability, forgetfulness and depression and hypertension might follow. The patients are generally obese with short and thick necks; they also have narrow upper respiratory tracts. This body composition is not a rule though; people from all age groups including children might have obstructive apnea. CSA might be due to lesions of the brain stem and regions associated with the regulation of breathing. Furthermore, heart failure, metabolic and toxic encephalopathies might lead to central apnea (CA). CSA might happen both in sleep and during wakefulness (5-8). The clinical presentation of OSA may overlap substantially with that of major depression, including report of poor sleep quality, daytime fatigue, difficulty concentrating, cognitive deficits and somatic symptoms such as headaches. Since the depressive phase of BD is often chronic and difficult to treat, and undiagnosed underlying medical conditions may greatly contribute to its unfavorable outcome, it is reasonable to speculate that sleep-disordered breathing may play a role in this clinical picture (10-12). OSA is a fully described and well-recognized entity. CSA, however, has been poorly studied. The prevalence of OSA is expected to be high in BD due to accompanying comorbid obesity. There is no evidence according to frequency of CSA in the patients with BD. Coexistence of CSA and BD has not been previously reported.

Case (History)

31 years old, Body Mass Index: 30.5 (obesity), male patient with BD was admitted to the sleep disorders center, electrophysiology laboratory with complaints of daytime sleepiness. Fragmented sleep was also detected in the patient who underwent a one-night sleep test (Polysomnography (PSG)). Respiratory findings in PSG (shown in the Figure): Apnea-Hipopnea Index (AHI): 75.5; supine AHI: 150; total number of the CA: 377/ one night; number of CA in the supine position: 280/ one night were particularly striking. 8 cmH2O automatic Continuous Positive Airway Pressure (CPAP); with a diagnosis of Central Sleep Apnea Syndrome (CSAS) therapy was started. Daytime sleepiness disappeared within 1 week, but on the 8th day, her husband told her that she strangled her mother in her sleep, the patient began to wake up very early (in the morning: 3), her mood and energy increased during the day, and her concentration deteriorated. Only the quetiapine dose of the patient who used 1200mg/day lithium (therapeutic index) was increased. The patient voluntarily discontinued CPAP. (Figure 1)

It shows the sleep histogram taken from the PSG recording of the patient with BD. Stage, Stages of sleep (N1: NREM1, N2: NREM2, N3  NREM3, R: REM, W: Awake); SaO2, Arterial Oxyhemoglobin Saturation (%)

Figure 1: It shows the sleep histogram taken from the PSG recording of the patient with BD. Stage, Stages of sleep (N1: NREM1, N2: NREM2, N3 NREM3, R: REM, W: Awake); SaO2, Arterial Oxyhemoglobin Saturation (%)

Respiratory Event (pink lines indicate CA occurring during the night). Note the relationship between Stage and Respiratory Event for the cause of fragmented sleep: Sleep deprivations are seen due to CA. Also note the relationship between Respiratory Event and SaO2: Blood oxygen levels of case with BD cause serious decreases (blue areas) between CA events (pink lines) (NREM: Non Rapid Eye Movement, REM: Rapid Eye Movement).


CSA is prevalent in patients with heart failure, healthy individuals at high altitudes, and chronic opiate users and in the initiation of “mixed” (that is, central plus obstructive apneas). CA is their predominance in NREM sleep and especially in lighter sleep stages as well as their relative scarcity in phasic REM sleep (13-15). Physiologically, control of breathing during sleep is critical. It is important to understand the basic respiratory mechanisms in the pathophysiology of CA. In particular, metabolic control (chemoreceptors in the medulla sensitive to CO2), as well as intrapulmonary receptors directed by vagal nerves, regulate respiration via the brain stem (of course with the help of O2 and CO2 sensitive carotid body receptors). If the CO2 level is low at sleep onset, respiration cannot be stimulated (sleep onset CA). The chemosensitivity of patients with central alveolar hypoventilation and obesity hypoventilation syndrome decreases during the day; CA is rare, these patients experience hypoventilation especially during REM (hypercapnic respiratory failure). Increased CO2 chemosensitivity (idiopathic CA) too little CO2 increase during sleep causes disruption of respiratory rhythm. Periodic central apneas (Cheyne Stokes breathing (CS)) are seen in heart failures with low left ventricular ejection fraction and atrial fibrillation. The frequency of CS and CSA in the REM period is low. CSA occasionally emerge with CPAP titration of sleep-disordered breathing (complex sleep apnea), also can occur in patients on opiates (16-19). Our case was on regular BD treatment and had no substance abuse (opiate). CAs revealed in PSG disappeared during CPAP titration. Could CAS have a relationship with BD and the drugs it uses? Quetiapine mechanism of action might involve rapid dissociation from D2 receptors. Atypical antipsychotics treat manic symptoms associated with BD by blocking dopamine D2 receptors; Side effect is weight gain. Patients with a high baseline body weight are more likely to gain weight while taking lithium. Our case was obese; hypoventilation, heart failure was not detected. Maybe the CAs that emerged were related to high altitude (Our city, Erzurum, is 1900m above sea level). Or idiopathic CA may have been seen together with BD. So far, no case of coexistence of CSAS and BD has been reported. Our case, in which we could not see CA in REM processes in PSG, got up at night and strangled her mother. Does CPAP therapy also cause REM behavior disorder in BD patients?

As a result, CPAP application in a patient with BD, regardless of etiology, caused a new manic episode to occur.


Psychiatrists, clinicians, especially laboratory physicians who record electrophysiological signals; It should be kept in mind that CPAP therapy, which is initiated in patients with BD, will worsen manic symptoms, shorten sleep duration, and cause REM behavior disorder while treating sleep apnea.


1. American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders. APA; 2013.

2. Muneer A. Mixed states in bipolar disorder: etiology, pathogenesis and treatment. Chonnam Med J. 2017; 53: 1-13.

3. Merikangas KR, Jin R, He JP, et al. Prevalance and correlates of bipolar spectrum disorder in the world mental health survey initiative . Arch Gen Psychiatry. 2011; 68: 241-251.

4. ?Chengappa KN, Suppes T, Berk M. Treatment of bipolar mania with atypical antipsychotics. Expert Rev Neurother. 2004; 4: 17-25.

5. Kayabekir M. Sleep Physiology and Polysomnogram, Physiopathology and Symptomatology in Sleep Medicine. 2019: 5-12.

6. Malow BA. Approach to the patient with disordered sleep. Impact, presentation, and diagnosis. 2005: 589-593.

7. American Academy of Sleep Medicine, editor. International Classification of Sleep Disorders, Diagnostic and Coding Manual. AASM; 2005.

8. Kayabekir, M. Updates in Sleep Neurology and Obstructive Sleep Apnea. 2020: 1-13.

9. Kryger MH, Roth T, William CD. Sleep Breathing Disorder. In: Principles and Practice of Sleep Medicine. 2011; 1208-1211.

10. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. 2004; 291: 2013-2016.

11. Hattori M, Kitajima T, Mekata T, Kanamori A, Imamura M, et al. Risk factors for obstructive sleep apnea syndrome screening in mood disorder patients. Psychiatry Clin Neurosci. 2009; 63: 385-391.

12. Soreca I, Levenson J, Lotz M, Frank E, and Kupfer DJ. Sleep apnea risk and clinical correlates in patients with bipolar disorder. Bipolar Disord. 2012; 14: 672-676.

13. Javaheri S, Dempsey JA. Central sleep apnea. Compr Physiol. 2013; 3: 141-163.

14. Fletcher EC. Recurrence of sleep apnea syndrome following tracheostomy. A shift from obstructive to central apnea. Chest. 96: 205-209.

15. Morgenthaler TI, Kagramanov V, Hanak V, Decker PA. Complex sleep apnea syndrome: is it a unique clinical syndrome? Sleep. 29: 1203- 1209.

16. Krimsky WR, Leiter JC. Physiology of breathing and respiratory control during sleep. Semin Respir Crit Care Med. 2005; 26: 5-12.

17. Joseph V, Pequignot JM, Van Reeth O. Neurochemical perspectives on the control of breathing during sleep. Respir Physiol Neurobiol. 2002; 130: 253-263.

18. Eckert DJ, Jordan AS, Merchia P, Malhotra A. Central sleep apnea: Pathophysiology and treatment. Chest. 2007; 131: 595-607.

19. White DP. Pathogenesis of obstructive and central sleep apnea. Am J Respir Crit Care Med. 2005; 172: 1363-1370.

20. Vestergaard P, Poulstrup I, Schou M. Prospective studies on a lithium cohort, 3: tremor, weight gain, diarrhea, psychological complaints.Acta Psychiatr Scand. 1988; 78: 434-441.

21. Vendsborg PB, Bech P, Rafaelsen OJ. Lithium treatment and weight gain. Acta Psychiatr Scand. 1976; 53: 139-147.

Kayabekir M, Eren F, Ceylan M, Bayraktutan ÖF, Alt?nkaynak K, et al. (2021) CPAP Induced Manic Episode in a Patient with Bipolar Disorder: A Case Report of Central Sleep Apnea. J Sleep Med Disord 7(2): 1125.

Received : 19 Sep 2021
Accepted : 28 Sep 2021
Published : 30 Sep 2021
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X