Practical Ways To Maintain Wellness

Amy, age 33, had a six-year history of bipolar disorder. Three years after being diagnosed, she began a period of rapid cycling that seemed to be provoked, in part, by an on-again, off-again relationship with her boyfriend. When she abruptly relocated out-of-state due to his business, her rapid cycling intensified. She obtained part-time work in her new city and sought psychiatric treatment. Her psychiatrist gave her a combination of lithium and Depakote, which helped even out her cycles, but she still experienced unpleasant ups and downs. Her sleep was quite variable from night to night.

Her psychiatrist suggested that she supplement her medication treatment with therapy from a psychologist with whom she (the psychiatrist) worked. The psychologist encouraged her to start a mood chart, in which she kept track of her moods on a daily basis, the number of hours of sleep she had each night, her medication, and any events that she found stressful, whether positive or negative. At first she found this assignment to be a hassle. She told her therapist that it took time and she didn't like being reminded of her illness so frequently. Her therapist acknowledged the discomfort of the assignment but reminded her that tracking her moods was a first step toward gaining more control over them. After some discussion she agreed to try it but made no commitment to keeping the chart on a regular basis.

Amy and her therapist began examining her charts during their weekly meetings. Over a period of several months, they began to identify certain behavioral patterns associated with Amy's mood swings. For example, Amy learned that her mixed mood states often began with a rejection by her boyfriend (such as being ignored or slighted by him in the company of others). Rather than directly confronting him about these experiences, she would usually go out drinking with her female friends that night or the next night. Her sleep would then become more disturbed, and her mood would take on an irritable, anxious quality. Her mood would usually stabilize once she had reestablished a regular bedtime and wake time.

She asked her friends whether they would feel any differently about her if she went out with them but didn't drink. None seemed particularly bothered by this, Although she did not stop drinking entirely, Amy did find that limiting her alcohol intake helped her sleep better, which in turn made her feel less irritable, anxious, and depressed the next day. She made clear to her therapist that she had no intention of giving up her "outrageous side." But with time, she has become more consistent with these lifestyle habits, pleasantly surprised by the beneficial effects they've had on her mood stability.

What can you do to maximize your intervals of wellness and minimize the time you spend ill? Many people go for long periods of time without having significant symptoms, but virtually everyone with the disorder has recurrences of illness at some point. In my experience, the people who do the best over time are those who not only take their medication regularly and see their doctors but also successfully implement self-management strategies.

What does it mean to manage bipolar disorder successfully? In Chapter 5 we talked about the risk factors in bipolar disorder (things that make your illness worse). There are also protective factors: things that keep you well when you are vulnerable to mood swings. You are already familiar with some of these protective factors from earlier chapters—for example, consistency with medication and having social supports.

In essence, maintaining wellness means minimizing the risk factors and maximizing the protective factors (see the table on page 153). Sometimes risk and protective factors are simply opposite sides of the same coin. For example, sleep deprivation is a risk factor, whereas staying on a regular sleep-wake rhythm is a protective factor. In other cases, protection involves introducing a new element into your daily life, such as keeping a mood chart.

Minimizing risk and maximizing protection will almost certainly improve your course of illness and the quality of life. But doing so can be difficult. It can require giving up things that you have come to depend on (for example, drinking alcohol to relax, staying up late at night). It will probably be impossible for you to avoid every risk factor and take full advantage of every protective factor in the table. For example, some people are able to stay scrupulously close to their medication regimen and have learned to avoid alcohol but find it impossible to prevent sleep disruption. Others are able to keep relatively consistent daily and nightly routines but find it difficult to regulate their exposure to family stress or other interpersonal conflicts. If you know yourself well, you may be able to decide which risk factors you can and cannot realistically avoid, and which self-management strategies are possible to implement within your current lifestyle.

This chapter will acquaint you with practical self-management strategies that fall into four broad categories:

• Tracking your mood through a daily chart

• Maintaining regular routines and sleep-wake cycles

• Avoiding alcohol and other mood-altering substances

• Developing and maintaining social supports

Risk and Protective Factors in Bipolar Disorder

Risk factors that increase your chances of becoming ill

Risk factors

Examples

Stressful life changes Alcohol and drug abuse Sleep deprivation

Loss of a job, gaining or losing a new relationship, birth of a child

Drinking binges, experimenting with cocaine, LSD, or Ecstasy, excessive marijuana use Changing time zones, cramming for exams, sudden changes in sleep-wake habits

High levels of criticism from a parent, spouse, or partner; Provocative or hostile interchanges with family members or coworkers

Suddenly stopping your mood stabilizer; regularly missing one or more dosages

Family distress or other interpersonal conflicts

Protective factors that help protect you from becoming ill

Protective factors

Examples

Observing and monitoring your own moods and triggers for fluctuations

Keeping a daily mood chart or social rhythm chart

Maintaining regular daily and nightly routines

Going to bed and waking up at the same time; having a predictable social schedule

Relying on social and family supports

Clear communication with relatives; asking your significant others for help in emergencies

Staying on a consistent medication regime, obtaining psychotherapy, attending support groups

Engaging in regular medical and psychosocial treatment

The strategies you'll learn will be of most help when you are feeling well or experiencing only mild mood swings. They can also help protect you from more severe bipolar episodes. Throughout the chapter, I show you how other people with bipolar disorder have used these strategies in their daily lives and how they have avoided some of the pitfalls associated with implementing them. Chapters 9, 10, and 11 give you tools to use when you want to stop a developing manic, depressive, or suicidal episode from spiraling beyond your control.

Maintaining Wellness Tip No. 1: Keeping a Mood Chart

If you've been seeing a psychiatrist for a long time, you're probably familiar with some form of mood chart. If this is your first episode, your psychiatrist or therapist may not have introduced this assignment yet. A mood chart is simply a daily diary of your mood states, with dates indicating when these moods start and stop. The chart can also incorporate information about your sleep, medication, and life stressors.

Why should you keep a mood chart? First, becoming aware of even subtle changes in your mood and activity levels will help you recognize if you are having a mood disorder relapse and determine whether you should contact your doctor to see if a change in medication would be helpful. Many bipolar people have been able to "head off at the pass" their episodes by observing the minor fluctuations on their mood charts, which often herald the onset of major manic, mixed, or depressive episodes. A picture is worth a thousand words!

Second, your doctor will find the chart useful, in that he or she will be able to see how well your medication is working or, alternatively, when it is making you feel worse (such as when antidepressants bring about rapid cycling). He or she may also want to monitor symptoms other than mania or depression, such as your anxiety, sleep disturbance, or irritability.

Third, you can use your mood chart information to identify environmental triggers of your mood cycling, which can then lead to stress-management strategies to lessen the impact of these triggers. With time and practice, many of my clients have become effective at identifying stress triggers, such as the onset of their menstrual cycle, arguments with particular family members, or work stress. Amy, for example, came to recognize through mood charting that conflicts with her boyfriend were a trigger for her mood cycling. She also found that her usual strategy for coping with distress—going out drinking— was contributing to her irritable mood states for several days later. This realization did not stop her from drinking altogether, but it did make her weigh the pros and cons of alcohol as a means of self-medicating her emotions.

The chart on page 156 is used in the NIMH Systematic Treatment Enhancement Program for Bipolar Disorder (Sachs, 1993, 1998). There is a blank version of this chart at the end of the book that you can copy for your own use, or you can download it from www.manicdepressive.org. The website also contains instructions for filling out the chart, which are also detailed below. Each chart allows you to track your moods for up to one month. So, if you have started the chart in the middle of the month, continue to use the same sheet until the middle of the next month, and then begin a new sheet. In other words, "day 1" need not be the first of the month. It could be the 10th, and day 10 could be the 20th.

People with bipolar disorder find this to be a "user-friendly" method of recording the cycling of their moods over time, even though it looks intimidating at first. Once you get used to it, you can usually fill it out in a few minutes each day. 1 usually suggest that people keep the chart on an indefinite basis, but if this seems daunting then try it for a month or two to see if it proves useful. After that, you may decide to chart your moods in a different way (or your doctor may have another chart for you to use).

For now, let's consider Amy's mood chart, which she completed during a month in which she experienced significant mood fluctuations. Her "X" marks indicate her mood states on any given day. Notice that on some days she has made two ratings, one for mania and one for depression (her mixed mood states).

Amy identified some of the factors that contributed to her mood swings, including life events such as the illness of her dog. Her mood had been relatively stable (note the absence of "peaks" between the argument with her dad and the rejecting event with her boyfriend), but then she stayed out late at a concert and experienced a hypomanic period. By day 16 of the month, she'd had seven consecutive nights of poor sleep and began to experience mixed mood symptoms. Her medication was not changed during this interval, but she had been inconsistent with her regimen during days 10 and 11. So she identified four things that may have correlated with her mood shifts during this particular month: events involving her pet, problems with her boyfriend, sleep deprivation, and medication inconsistencies.

We don't know for sure whether these variables would have affected Amy's moods during a different month. This is one of the reasons it is important to keep the chart on an ongoing basis—to determine whether you have a predictable set of "mood triggers" (for example, arguments with family members, final exams, changing time zones, a specific pattern of sleep deprivation). Identifying mood triggers is an important step in gaining control over your moods, as you'll learn more about in this and subsequent chapters.

Name Amy

TREATMENTS (Enter number of tablets iaken each day)

Monlh/Year

August 2000

Daily Notes

MOOD

Rale with 2 marks each day to Indicate besl and worst (if applicable) Depressed WNL Elevated

3 - seuBre a rtaumcrit nvTth

Severe

Mod.

fif hS

Mild

MOOD NOT DEFINITELY ELEVATED OR DEPRESSED.

NO SYMPTOMS

Circle date to indicate Menses

Mild

Mod.

Severe

boyfriend rsltKtinfl concgrt. staygri out until 3am

10 5

¿jpg out of- hogpltäl frlgnd's wadding coplfiflg jT1d3t of Ehe jjgy

Wei ant: 127

Notr. WML = Within normal limits. Adapted by permission of Gary Sachs, MD (Copyright 1993),

Amy's Self-Ra ted Mood Chart.

Step J: Rating Your Mood Each Day

The first step in learning to fill out a mood chart is to become familiar with a numerical scale that corresponds to various levels of your mood disturbance. The sidebar gives you guidelines for making judgments about your daily mood, using a scale from -3 (severe depression) to +3 (severe mania). It gives examples of how people with bipolar disorder feel and think (and what they say) when they're in these various states (see also Young et al., 1978). Not every example or descriptive label in the table need apply to you in order to use the corresponding scale number. Rather, try to figure out which category of depression or elevation best describes how you feel on a given day.

Mood charting requires a bit of practice. You may be a person who is naturally able to judge for yourself whether you are feeling manic or depressed, and you may be easily able to describe the experience to others. Alternatively, the descriptive label "manic" or "depressed" may not fully capture the way you feel. If this is the case, take time to learn the mood chart and numerical scales and try to see if you can equate the terms used in the chart with your particular way of describing mood states. For example, depressed can mean the same thing as "crashed"; elevated can mean the same thing as "wired."

Practice by seeing if you can apply a mood descriptor to your mood today and yesterday, using the -3 - + 3 scale. If you are unsure as to whether your rating is reasonable, ask someone who knows you well (perhaps a family member or your partner) if he or she would agree with your rating. If you feel that your mood varies considerably during the day, make a "best" and a "worst" rating (for example, you may be at a -2 in the morning and a -1 or 0 by evening). If your mood has been both elevated and depressed on the same day, make two ratings, indicating the highest and lowest points.

In choosing your level, try to think about the least and most depressed or manic you've ever been in your life and determine where these states fit on the scale. For some people, their worst period ever might have been a —1; for others it might have been a -3. If your mood has never gone above or below a 2, use these as benchmarks for judging your mood today and throughout the week.

Compare your depression level today against a typical day (your baseline, or how you feel most of the time, which would rate a 0). Then compare your mood to other days when you felt blue or out of sorts but not impaired (-1), days when you have felt impaired but could still function with significant difficulty (-2), and, if applicable, days when you felt so down that you could not work at all or interact with others (-3). These comparisons should help you determine today's rating. Likewise, try to think of the most manic or hypomanic you've ever felt. If you were ever severely manic and in the hospi-

158 sm-mmmm

Mood Descriptors

(0) "WNL" (within normal limits). This is your baseline: Your mood is not elevated or depressed, your energy level is normal for you, sleep is normal, and you're able to carry out your daily work and other tasks with little or no difficulty. You have no other obvious symptoms of your mood disorder.

Elevated Mood

{+1) Mildly elevated. You are feeling giddy, cheerful, or energized, or somewhat more irritable or anxious or nervous than usual, but you are not really impaired; you have more energy and more ideas, and you feel more self-confident but have been able to work effectively and relate normally to others. "I'm more restless/animated/talkative today than usual," "I'm making more phone calls," "I'm getting by with a little less sleep" (for example, one or two hours less than usual), "I'm more easily distracted today," "I'm snapping at people more," "I'm more frustrated by little things," "I'm somewhat revved up or wired," "My mind is clicking along a little faster," "I'm feeling sexier," "I'm more optimistic," "I'm hypomanic."

(+2) Moderately elevated. "High" or moderately manic; your mood is euphoric or very irritable and anxious, and people have told you it seems inappropriate; you feel like breaking things; you feel heavily goal-driven and hypersexual and your thoughts are going very fast; you have significant difficulty focusing on your work; you are having run-ins with people (they seem to be moving and talking too slowly); people are complaining that you seem angry or grouchy or are moving way too fast; you yelled at others inappropriately. You are sleeping as little as four hours per night and not feeling tired. "I'm feeling very impatient today," "1 think I can get by with a lot less sleep," "I'm very preoccupied with sex," "My mind is working faster than ever," "I have so much to say and I hate being interrupted," "I'm feeling irritated, angry at everything."

(+3) Severely elevated/manic. Euphoric or aggressive; you are laughing constantly or your irritability is out of control; you have had loud verbal or physical fights with people; you feel like you are exceptionally talented or have special powers (for example, the ability to read people's minds, to change the weather), you are constandy moving about and cannot sit still; you are unable to work or get along with others; you have gotten in trouble in public, have been stopped by the police or have been taken to the hospital; you are sleeping little or not at all.

Depressed Mood

(-1) Mildly depressed. You are feeling slightly slowed down or sad; you have trouble keeping certain negative thoughts out of your head; you feel more self-critical, you want to sleep more or are having slight trouble falling or staying asleep, and you feel somewhat more fatigued than usual; you wonder if life is worth living; things don't seem as interesting as they usually do; you are still able to work effectively and are relating normally to others, even though you may feel less effective; your depression is not obvious to others.

(-2) Moderately depressed. You are feeling very sad, down in the dumps, hopeless, moderately slowed down, or uninterested in things for most of the day; you are sleeping more or having a lot of trouble falling asleep or staying asleep (for example, waking up regularly in the middle of the night); fewer and fewer things are of interest to you; you are ruminating a lot about current or past failings; you are feeling grouchy and irritable; you have significant difficulty getting your work done (missing days at work or school or being less productive); your concentration is impaired; others comment that you seem morose or slowed down or that you're speaking slowly; you have considered suicide and have thought of various methods.

(-3) Severely depressed. You feel deeply sad or numb; you have lost interest in almost everything; you are experiencing severe suicidal feelings, you wish to die or have made an attempt on your life; you feel extremely hopeless; you believe you have sinned terribly and should be punished; you are unable to work, concentrate, interact with others, or complete self-care tasks (for example, bathing, washing clothes); you stay in bed most of the day and/or cannot sleep and have severe problems with lack of energy.

Sources: Sachs (1998); Young et at (1978); Wiliiams (1988)

tal, your rating at that time would have been a +3. if you have ever been elevated to the extent that you were having trouble functioning at work, your rating would be a +2. If you have been "wired" and "upbeat," but this state did not cause run-ins with others or make it difficult to sleep, a +1 (hypomanic) probably applies. In other words, think in terms of your own personal benchmarks.

Step 2; Recording Your Anxiety and Irritability

You'll notice that the mood chart also asks you to rate your anxiety and irritability levels on a 0-3 scale. There are two reasons to do this. First, anxiety and irritability can be the first signs of a new manic or mixed episode. Second, some medications may produce these symptoms as side effects (for example, the SSRI antidepressants). So, it's a good idea to track these symptoms, even if you're not sure how they are related to the cycling of your bipolar disorder.

Examples of "1" levels of irritability include feeling somewhat snappish or grumpy, but not to the extent that you can't function alongside people. A "2" would mean moderate irritability that causes problems for you at work or at home. A "3" would mean that you were severely irritable and angry to the extent that you were having real trouble functioning. Likewise, a "1" anxiety rating would mean feeling mildly jittery, apprehensive, and perhaps scared but able to get along with minimal extra effort. A "2" would mean moderate anxiety that makes it difficult to work, read, socialize, or perform daily chores; however, you're still able to function with extra effort. A "3" would mean overt panic and severe, incapacitating anxiety.

Step 3: Recording Your Hours of Sleep

Along with your mood rating, make a daily rating of how many hours of sleep you had the previous night. If you're rating your mood for, say, Thursday, record the hours you slept Wednesday night to Thursday morning. If your sleep is intermittent, try to estimate the actual number of hours you were asleep. Your recall of your prior night's sleep may be most accurate when you first wake up in the morning.

If you take naps regularly, separately recording nighttime and daytime sleep will allow you to investigate whether napping in the afternoon makes it harder to sleep that night or makes your mood worse by the end of the day.

After a week or more of doing this charting, you may begin to see how your sleep and mood are related. Many people are surprised at the result.

Amy, for example, had always assumed that lack of sleep caused her to get more depressed, yet she found from her mood charting that sleep loss was more consistently associated with her hypomanic periods (note the shift on day 10 of her chart).

Step 4: Taking Daily Notes on Life Events and Social Stressors

If you feel that your mood has been influenced by one or more events or interactions with others, record these on your chart under "Daily Notes." Some of these may be significant (for example, breaking up with your partner, quitting your job) and others may seem minor (having a change in work hours; racing to the airport to catch a plane; getting stuck in a traffic jam). Record all events that you feel may be important, even if they seem as if they would be inconsequential for many people. For example, Amy found that even relatively routine quarrels with her father were associated with a mild drop in her mood (to a -1). The purpose here is to observe the connection between specific events and specific mood changes. When reviewing the day and filling out your chart, consider questions such as the following:

• What happened right before I last felt irritable or hypomanic?

• What happened right after my irritable mood set in?

• What happened right before my mood spiraled downward?

When you're recording stressors, recall the issue raised in Chapter 5: it can be difficult to tell whether stress was the cause or the effect of your mood. Over time, mood charting may help you determine the timing of events in relation to changes in your mood. For example, did you race to the airport and then feel an increase in your energy level and mood, or were you feeling speedy before you raced to the airport? Did you get into an argument with your father and then feel down about yourself, or were you feeling down before you got into the argument? Don't worry for now if you're not sure which caused which. Instead, just try to identify the factors that coincide: stressful events, mood states, and sleep patterns.

The "Daily Notes" section is also a good place to record your alcohol or drug use. If you drank on a specific day, record that information as an event even if your intake seemed trivial (for example, "drank one beer" or "had a margarita"). Then you can observe for yourself whether, and to what degree, alcohol or drug usage affects your mood the next day. You may also learn whether you are using substances, in part, to alleviate a negative mood state from the previous days or week.

Step S: Recording Your Treatments

Record all of the medications and dosages you are supposed to take at the top of the left columns of the chart, including medications that are not specifically for your bipolar disorder (for example, blood pressure pills). In the boxes corresponding to the day of the month you're rating, record the number you actually took. This will help you, your physician, and other members of your treatment team to know if inconsistencies in your use of medication is affecting your day-to-day mood. Amy missed her evening dosages on the night she went to the concert and the next evening as well, which probably contributed to her mood instability. As I talk about in Chapter 7, most people miss a medication dosage once in a while, but it's important to keep track of these seemingly minor inconsistencies. Likewise, place a check mark next to any days when you attended a psychotherapy session. As with medication, some people are quite regular and others are quite irregular in their therapy attendance.

You may be taking some of your medications "as needed." For example, some people take a medication like Klonopin only when they can't get to sleep. Indicate "as needed" on the top left column of your mood chart next to medications that fit this description. Some people find that their mood is lower on the day after they have taken an as-needed medication. Others find that certain as-needed medications (for example, the allergy medication pseudoephedrine) make them feel temporarily energized, wired, or even hypomanic.

Your physician will be able to use your medication records in a number of ways. Let's imagine that he or she has prescribed Depakote and an SSRI antidepressant. Let's also imagine that your chart indicates improvements in your mood a week or two after you started the SSRI, but then you began to report "roller-coastering" or rapid cycling of your emotions and energy levels. If all of this is documented on your chart, your physician may decide to discontinue the antidepressant or adjust your dosage as a way of stabilizing your mood.

Step 6: Recording Your Weight and Menses

Two other pieces of information will help round out your mood chart. First, record your weight at least once during the month. It's best to weigh yourself on the same day each month so that you can see whether your medication, stress, or mood cycling is connected with changes in your weight. For example, if you are gaining weight on an atypical antipsychotic (for example, Zyprexa), your physician may choose to switch you to a different medication within the same class (for example, Risperdal) or adjust your dosage. If you are a woman, circle the days on which you had your period. You and your doctor may wish to examine whether your mood cycles begin before, during, or after the onset of your menses.

Evaluating Your Mood Chart

Share your completed mood chart with your therapist or physician during each visit. Together, you can evaluate the influence of certain stressors on your mood, the influence of sleep disturbances, and the effects of various medications and your consistency with them. Even if you're not meeting regularly with your doctor or therapist, make a point of examining the chart at the end of each week to see if any patterns jump out at you. Keeping the chart over a year or more will enable you to develop longer-range hypotheses about which biological or social factors are provoking shifts in your mood (for example, periods of greater alcohol or marijuana usage, the onset of winter, the onset of spring, the Christmas holidays, periods of increased work or school stress).

Problems with Mood Charting

Mood charting can feel reductionistic: It does not do justice to the many varied experiences you have on a daily basis. It is also very present-focused. Some people feel that their mood shifts are related to factors that can't be easily recorded on the chart (for example, traumatic events in the recent past or in childhood). Even with these limitations, however, mood charting is a very efficient way of summarizing a great deal of information very succinctly for yourself and your doctor. If you are using mood charting as a supplement to your personal psychotherapy, think of it as a point of departure for exploring larger issues that affect your mood. For example, events such as minor disagreements with a partner can have profound effects on your mood if they trigger fears of separation or loss. You may wish to explore these larger issues with your therapist.

Mood charting can also be difficult to remember to do every day. Try to pick one time each day to complete your chart, and stick to this time on a day-to-day basis. Some people fill it out right before getting ready for bed; others tie mood charting to a specific daily activity (for example: just after finishing dinner, after walking the dog, before watching the evening news). Avoid choosing the worst moment of the day to fill out the chart if that moment does not represent how you've felt for the whole day. So if you usually feel quite unhappy when you first wake up but feel better within half an hour or so, pick another, more representative time of day. Avoid trying to fill out a month's worth of mood charts just before your doctor appointments, as people sometimes do. The more accurate the information you convey to your doctor, the better the treatment decisions you and your doctor can make.

Maintaining Wellness Tip No. 2: Maintaining Regular Daily and Nightly Routines

"I really feel that 1 benefited from psychoanalysis, I was in it four times a week. But I don't think it was all that learning about my childhood. There was something very therapeutic about always having a place to go to in the morning, seeing the same therapist every day, seeing the same attendant in the parking lot, getting back in my car at the same time ... I found all of that structure very comforting."

—A 40-year-old woman with bipolar II disorder

In Chapter 5, I talk about the beneficial effects on your mood stability of external "time keepers," and the potentially negative effects of events or social demands that disrupt your daily routines and sleep-wake cycles (Ehlers et al., 1988, 1993), Actively maintaining daily and nightly routines is one of the most important behavioral changes you can undertake—aside from regularly taking your medication—to help keep you in the driver's seat in managing your disorder. In this section, 1 discuss the "social rhythm stability" approach to maintaining wellness.

Keeping a Social Rhythm Chart

The Social Rhythm Metric (SRM) is a more time-consuming device than the mood chart, but it is also potentially more informative (Monk et al., 1990, 1991). In this chart, you keep track of when you eat, sleep, exercise, and socialize, and make ratings of your daily mood. With time, you can work on stabilizing your daily routines as a means of stabilizing your mood. This involves planning your regular activities for predictable times of the day or night.

The SRM was developed as a central part of Ellen Frank's and David Kupfer's work on interpersonal and social rhythm therapy (IPSRT). As I talked about in Chapter 6, Frank and her colleagues have shown that the combination of IPSRT and medication is effective in improving the course of bipolar disorder (Frank, 1999; Frank et al., 2000). I was trained in Frank's social rhythm therapy approach some years ago and have become convinced of the value of daily rhythm tracking and stabilization for persons with bipolar disorder.

The purpose of social rhythm tracking is to allow you to discover the relationship between changes in your daily routines, levels of interpersonal stimulation, sleep-wake cycles, and mood. Over several weeks or months, you will begin to see certain patterns emerge (as Amy did). For example, you may find that changes in your activity levels or sleep patterns presage the development of new episodes. In the beginning phases of mania you may observe a gradual decrease in the time you spend sleeping and an increase in the time you spend exercising. Likewise, you may find that as you recover from a manic or depressive episode, your activity and sleep patterns naturally go back to the way they were before you became ill. In other words, your sleep and activity patterns can be a sign of whether your mood problems are getting better or worse.

As with the mood chart, it's best to fill out the SRM every day and review it each week by yourself and with your therapist or psychiatrist. Keeping the social rhythm chart on a regular, ongoing basis will enable you to spot shifts in your daily routines and sleep-wake cycles that may be of subtle importance in determining your mood.

The chart on page 166 was completed by Leslie, a 40-year-old woman with bipolar I disorder (a blank Social Rhythm Metric form is provided at the end of the book). First notice the upper left-hand corner, where she has made a daily mood rating on a -5 - +5 scale. In this respect it is like the mood chart. But notice that there are 17 activities listed on the left side; most people will do some portion of these every day. Indicate in the boxes what time you did these activities: what time you woke up, had your first cup of coffee, went to work, went to school or did some other daily activity, ate lunch, exercised, came home, ate dinner, and went to bed. These daily routines, in part, "drive" your sleep-wake habits (Frank et al., 2000). For example, if you have a shifting work schedule that demands that you work from 8 a.m. to 4 p.m. one day and then 4 p.m. to 12 a.m. the next, your bedtime and wake time will be correspondingly altered from day to day, and your mood may change (up or down) in the days that follow. In contrast, if you eat, exercise, work, and interact with others at fairly regular times of the day or evening, you will come to expect sleep at a certain time.

The SRM also asks you to record who did each of these activities with you and how stimulating they were. The degree to which your interchanges with others are provocadve, conflict-ridden, or otherwise stimulating, versus low-key or "laid back," can be important determining factors in the degree of stability you experience in your emotional states and possibly even your sleep. Say you ate dinner with your wife or husband but had an argument, and then

THE SOCIAL RHYTHM METRIC (SRM) MacArthur Foundation Mental Health Research Network I

Please Fill This Out At The End Of The Day

Day of Week: Sun Date: b-2b

MOOD RATING (Choose one): -2

Scale

-5 -4 -3 (-2) -1 0 1 2 3 4 5 Very Depressed Normal Very Elated

Check If DID NOT DO

TIME

1 = Just Present

2 = Actively Involved

3 - Others Very Stimulating

CLOCK TIME

Check

Spouse/ Partner

Children

Other Family Members

Other Perso n(s)

agitated nervous ACTIVITY irritable

A.M.

P.M.

SAMPLE ACTIVITY (for reference only)

6:20

2

1

OUT OF BED

9:30

V

V

FIRST CONTACT (IN PERSON OR BY PHONE) WITH ANOTHER PERSON

10:00

V

2

HAVE MORNING BEVERAGE

9:30

V

t

HAVE BREAKFAST

10:00

V

2

GO OUTSIDE FOR THE FIRST TIME

10:45

3

START WORK, SCHOOL, HOUSEWORK, VOLUNTEER ACTIVITIES, CHILD OR FAMILY CARE

V

HAVE LUNCH

12:00

3

TAKE AN AFTERNOON NAP

HAVE DINNER

7:3 0

V

PHYSICAL EXERCISE

5:30

V

V

HAVE AN EVENING SNACK?DRINK)

9:00

V

V

WATCH AN EVENING TV NEWS PROGRAM

10:00

V

V

WATCH ANOTHER TV PROGRAM

V

ACTIVITY A

Vhone conversation

9:30

3

ACTIVITY B

RETURN HOME (LAST TIME)

7:00

V

2

GO TO BED

10:00

V

A social rhythm chart. Copyright 1991 by Elsevier Science. Reprinted by permission from Monk et al. (1991).

the two of you went to opposite ends of the house (rated a "3" on stimulation); you would probably have more trouble falling asleep that night. Compare that night to another night when you and your spouse had a relaxing dinner together (which might be rated a "1"—'"others just present").

High levels of stimulation from other people can feel quite positive but still affect your mood or sleep-wake cycle negatively. Deborah, age 26, found that her evening waitressing job at a bar, which she enjoyed a great deal, contained highly stimulating bursts of activity (usually three-hour blocks in which she was in great demand by the patrons). She consistently had more trouble falling asleep after getting home than she did on nights when she wasn't working. She had an easier time when she was assigned the early evening shift.

Katherine, age 42, enjoyed the intensive contact with people she had through her job in the clothing section of a department store. However, the social stimulation rose to almost intolerable levels during the weekends prior to the Christmas holidays, and she found herself becoming increasingly irritable. She learned not to schedule any social activities on the weekend evenings following these workdays as a way of modulating her exposure to stress and stimulation.

£es//e's Example: Evaluating a Social Rhythm Chart

Although only one day is shown in Leslie's example on page 166, we can develop some hypotheses about factors that affected her mood states. For her, a mixed mood state is a day of depression, along with agitation, nervousness, and irritability. Note that even though the sample day occurred during the spring, when daylight hours were longer, she still had a relatively short day (woke up at 9:30 a m. and went to bed at 10 p.m ). She was sleeping too much. She also had several high-stimulation interactions during the day (including an argument over the telephone with her ex-husband about their child, and a confrontation with a roommate whom she felt was being inconsiderate). She had at least one alcoholic drink when alone. In addition to her biological predispositions, these factors may have partially determined her agitated, depressed mood.

It is possible that these events and activities resulted from her mood state (for example, she might have been anxious and irritable and therefore more prone to confrontations). To help determine which caused which, Leslie collected social rhythm and mood information on herself over a period of several months. She began to see how provocative interactions with certain people, sleep patterns, and alcohol combined to change her mood, as well as how her mood states affected the timing and frequency of these events and habits. She became increasingly certain that alcohol before bedtime and sleeping more than nine hours combined to make her nervous and irritable and more prone to run-ins with people.

"How Can I Regulate My Daily Routines?"

The next step is to devise strategies that help you regulate your daily routines. Keeping regular routines sounds straightforward, but if you've ever tried to do it, you know that significant challenges are likely to arise. You can do this alone, but a therapist may be able to help you develop and keep "target times" for various activities such as sleep and exercise.

The first, most important ingredient is to go to bed at the same time every night and wake up at the same time every morning. Try to maintain this pattern on weekends, even when you'd rather sleep late. Of course, there will be times when getting to bed at your target hour or waking up at a specific time is impossible, such as when you travel, have social plans on a weekend, have a sick child, or need to get up extra early to pick up someone at the train station. Some of these events will be controllable by you (for example, whether to go to the early or late showing of a certain movie) and some will not (for example, the timing of an airline flight). If your schedule is shifted by an hour or two on a given night, try to reinstate your original sleep-wake target times as soon as possible.

Try to maintain your sleep patterns even if events conspire to make you change them. For example, if you have lost your job, try to get up at the same time you would have gotten up when you were going in to work. If your new job requires different hours (say, getting to work by 8 a.m. instead of 9 a.m.), adjust your bedtime to an hour earlier. It's best to ease into your new schedule gradually rather than suddenly.

You can also work with your therapist to anticipate events that will change your daily routines, and plan ways to regulate yourself once these events occur, For example, if you know that you may be changing jobs soon or traveling more in the near future, you can anticipate that your sleep will be disrupted. Make plans, in advance, to go to bed and wake up at consistent times, even after these disruptive events have occurred.

Second, if you have been having trouble sleeping (see the section on sleep, below), try to avoid "sleep bingeing," in which you catch up from all the lost sleep during the week by sleeping more on weekends. You'll probably find that sleep bingeing has a negative impact on your mood (typically depression; see, for example, a study of sleep disturbance by Wolfson <Sr Carskadon, 1998). It also makes it harder to sleep the next night.

Third, try to see if you can maintain the same hours each day at work or school. For example, try to take classes during the same interval each day. Try to avoid having all of your classes on one or two days and none on the other three. To parallel your regular job hours, try to exercise at the same time (for example, just after work) rather than late in the evening on one night and then early in the morning the next day. Try to have a regular period to unwind before going to bed. Avoid having your most stimulating interactions with partners, friends, or coworkers right before you try to go to sleep.

Practical Challenges to Maintaining Regular Routines

There are practical problems to be solved, of course. The courses you want to take may be offered at all different times of the day or night. You may have a job that requires a lot of travel, necessitates long shifts on weekends, requires work at home in the evening on some nights but not others, or involves changing shifts. An example is a contract nursing job, in which people are often called for a full eight-hour shift only an hour before the shift is to start. Restaurant jobs often have shifting schedules as well. In Chapter 12, you'll find some suggestions for negotiating work hours with your employer in light of the limitations your disorder can impose.

Here are examples of how some of my patients have kept regular social rhythms even when facing the demands of school or job. Walter had an open discussion with his employer about his mood disorder. His employer agreed to keep him on the 8-5 daily shift at his computer programming job, rather than the constantly variable shifts that were typical. Juanita, who traveled frequently, always tried to get the same number of hours of sleep each night, even when she was in a new time zone. Maintaining her sleep habits required a degree of assertiveness, given that she was often encouraged by her traveling coworkers to stay out late.

Candace (discussed more on page 179-180) found that her weekends involved long periods with little contact with others, and her depressions usually became worse then. Scheduling low-key activities with friends or acquaintances during weekend days gave her a greater feeling of consistency in routines from the week to the weekend and helped improve her mood. Likewise, Wesley, who became depressed after breaking up with his girlfriend, found that scheduling activities with other people each morning, or at minimum, taking trips to a coffee shop by himself, helped get him out of bed by a certain time.

The SRM can help you design a daily schedule of sleeping, eating, exercising, and socializing that is comfortable and feasible, given the demands of your current social, family, and work life. Try to set goals for when you plan to go to bed and when you want to wake up, and try not to deviate from these plans by more than 30 minutes to an hour, even when there are rewarding activities (for example, parties, late-night movies) that you feel would improve your mood. Other members of your family, if living with you (for example, your spouse or partner), may be able to help you design this program and stick to it.

Resistances to Tracking and Keeping Regulated Routines

Some people complain that social rhythm tracking is tedious and reminds them of doing homework assignments for school. Like most treatment and self-management techniques, the SRM is not without its costs in terms of time and effort. But as you get used to it, you will find that you can do it at the end of the day in about five minutes. With time, you may find that certain items on the chart are more important to record than others. For example, your bedtime, wake time, job hours, and exercise times may be critical in determining your mood stability, but your mealtimes or TV habits may be less central.

In my and other clinicians' experience, the bigger issue that people with bipolar disorder face is the trade-off involved in regulating their daily routines: It means giving up a degree of spontaneity. People sometimes wonder, "Why can't 1 have the same kind of 'devil may care' attitude that others have? if everyone else is staying up until 2 a m to party, why can't I?"

If you're having these reactions, that's understandable. For Amy, keeping a regulated routine made her feel that she was different from everyone else. On the other hand, she came to realize that the unpredictability and social stimulation she craved was like a drug. She usually had a "mood hangover" the next day.

There is comfort in knowing that you are doing something proactive to manage your disorder. You will almost certainly see benefits in terms of your mood stability and productivity when you structure your days and nights. With time, a regulated routine will give you a sense of security and control over your fate.

Even apart from the issue of mood stabilization, some of my clients find that social rhythm tracking helps them manage their disorder and lifestyle in ways they hadn't expected. For example, Carmen, age 29, found that SRM tracking helped remind her to take her medication, which until that point had been haphazard and unpredictable. After filling out his chart for several weeks, Arthur, 35, observed that "I have a habit of jamming in too many things to avoid depression, but then 1 get like a car that's run out of gas. I want contact with people, but 1 can get to the point where I'm doing too much. I need some more consistency, and 1 need not to be constantly overstimulated and running away from myself."

It is not only people with mood disorders who have to stay on regular, regimented schedules. Parents usually need to follow very predictable routines to manage the daily activities of their children. Athletes need to stick to well-regulated training schedules. People who become expert performers, such as accomplished professional musicians, have often developed highly regimented routines to help them accomplish their craft (for example, Krampe & Ericsson, 1996).

Nonetheless, if you're finding a regimented routine too stifling, discuss this with your doctors. There may be compromises that can be made. Perhaps you can identify the point at which fluctuating routines negatively affect your mood. For example, a 30-minute departure from your bedtime may make no difference, but 90 minutes might make a big difference. Try to see if you can identify the range of fluctuation in routines within which you can function and still feel stable,

"OK, Now That I'm Going to Bed on Time, How Do I Fall Asleep?"

"I toss and turn, look at the clock, sneer and snort through my nose, walk around the house ... do my yoga, do my meditation, turn on American Gladiators . . ., but I still can't sleep. It irks me to no end that my wife can just lie down and she's out, I almost want to wake her up to make her suffer like I am, but 1 don't. ... It goes like this every night, and then, of course, I'm a wreck at work the next day."

—A 51-year-old man with rapid cycling bipolar disorder

For some bipolar people, getting to bed at the right time isn't the main problem. The problem is falling asleep and staying asleep. There is nothing more frustrating than lying awake and trying to fall asleep. Sleep disturbance is a key symptom of bipolar disorder and sometimes can be a side effect of antidepressant medications. It can also be due to substances like caffeine, excessive sugar, tobacco, or alcohol, especially if these are ingested close to your bedtime.

Your doctor may decide to give you medications for sleep, such as Klonopin or Zolpidem (Ambien). Although these medications often work well, not everyone likes to take them because you can become addicted or tolerant (that is, you may need a bigger dosage over time to achieve the same effect). But you and your physician may decide that a sleeping medication is the best alternative in order to keep sleep disturbance from contributing to your worsening mood state.

Fortunately, there is a literature on behavioral interventions for sleep

Ways to Combat Sleep Disturbance

• Keep stress out of the bedroom

• Give yourself time to unwind before sleep

• Never "compete" to get to sleep

• Use muscle relaxation techniques

• Adjust your sleep cycle before travel

problems. Michael Otto and his colleagues at the Harvard Medical School/ Massachusetts General Hospital (1999) have developed recommendations for ways to improve sleep if you're suffering from bipolar disorder (see the sidebar on this page). Some of these sleep techniques would be applicable to people without bipolar disorder as well.

Examples of "stress in the bedroom" include having arguments with your spouse, preparing work assignments for the next day while in bed, examining your next day's work schedule, checking the stock market pages, checking your e-mail one last time, eating in bed, and making last-minute phone calls. These activities should be avoided right before bedtime. More generally, try to keep the last hour just before sleep free of stressful activities so that you can unwind and relax. If possible, try to arrange your bedroom such that noise is blocked out (for example, the telephone is turned off, no radios are playing) or wear earplugs.

Paradoxically, activities that people often take for granted as necessary for falling asleep may actually contribute to sleep disturbance. For example, many people watch the evening news in bed before turning out the lights, but the news overstimulates them and cranks them up. Likewise, many people feel they can't fall asleep without reading a book, yet sometimes reading, even if it's only a novel, can get the brain running in all sorts of different directions. If you've been reading a good murder mystery, it may be hard to put down and stop thinking about! Likewise, most people believe that regular exercise contributes to good sleep because it tires you out and relaxes your muscles. But it can also keep you awake if you exercise right before bedtime—try to give yourself as much as three hours between finishing your exercises and going to bed.

If you want to investigate which activities are contributing to your sleep problems, try nights with and without these activities and record the changes on your mood chart or SRM (for example, write "no TV" on Thursday night, and "yes TV" on Friday night, and record your sleep for each). Try to see if you can detect whether doing or not doing certain activities affects your sleep and mood.

Some people feel that falling asleep is like an athletic competition, like running a race in a certain time. Being unable to sleep makes them feel inadequate or incompetent, and "performance anxiety" begins to accompany their attempts to sleep. Try not to think of your ongoing sleep disturbance as something you're doing to yourself, but rather as a biological sign of your disorder. Rather than wrestling with yourself about being unable to sleep, instead experience the physical sensations of being in bed, including how your body feels, how you experience the covers over you, or how the pillow feels against your head. If you have access to a relaxation tape or meditation exercises, you may wish to use these to help you experience the physical sensations that lead to sleep (Otto et al„ 1999).

Many people have trouble sleeping when they travel. If you fly from the West Coast of the United States to the East Coast, you may arrive when everyone else is going to sleep, but for you it is three hours earlier. Transatlantic travel (for example, flying from Chicago to Paris) is particularly difficult for people with bipolar disorder because there is such a dramatic shift in circa-dian rhythms. But travel is often unavoidable.

One way to combat this travel disruption is to gradually adjust your internal time clock to the new place you're going, before you actually leave. So, over the course of the week before you travel to a later time zone, go to bed an hour earlier than usual, then an hour and a half, and then two hours earlier, and so forth. By the time you arrive, it may be easier to adjust to the hours of the new time zone. This procedure usually works best if you'll be in the new time zone for more than a few days.

There are other strategies you can use to improve your sleep, some of which go beyond our scope. If you've been having difficulties, consider reading self-help books specifically oriented toward sleep issues, such as William Dement and Christopher Vaughan's (1999) The Promise of Sleep or Peter Hauri and colleagues' (1996) No More Sleepless Nights.

Maintaining Wellness Tip No. 3: Avoiding Alcohol and Recreational Drugs

Ruth, a 32-year-old woman who had just been diagnosed with bipolar I disorder, had a severe problem with drinking that usually began when she was relatively free of bipolar symptoms. Typically, romantic relationships with men or conflict-ridden business entanglements were the background of these episodes. Her drinking binges were so severe that she often had to be hospitalized and detoxified. She went through an Antabuse program, in which she was required to come in twice a week to take a medication which made her vomit if she drank. But she quit this program and went back to drinking.

Her own view was that her bipolar disorder was making her drink. Many observers, including her doctors and family members, felt that it was the other way around: that her drinking came first and led to her mood cycling. She constantly complained of the pain of the mood swings and their associated anxiety, but her symptoms co-occurred so consistently with drinking that it was difficult to tell which were due to the bipolar disorder and which to the alcohol.

During one interval, Ruth became convinced that she should give up alcohol and stayed abstinent for almost six months. Her bipolar swings were much improved during this interval: She still had a mild depression but no mania or mixed symptoms. She was able to obtain a regular waitressing job and began functioning better than she had in a long time.

During this period of recovery, however, Ruth came to the conclusion that she had no real problem with drinking. She began to reinterpret her past almost exclusively in terms of her new bipolar diagnosis, denying any causal influence of alcohol. For example, she labeled her past alcohol binges as "rapid cycling" and "self-medicating." She reasoned that she wouldn't again lose control of her drinking since her mood disorder had become stable.

About five months into her period of abstinence, she traveled to Palm Springs for a weekend with her new boyfriend. Quite deliberately, she discontinued her Antabuse program five days before the trip. Within one week she was back in the hospital in need of detoxification. Her depression was much more severe upon her hospital discharge, and she enrolled, once again, in the Antabuse program.

Alcohol and Drugs: What Are the Risks?

Most psychiatrists and psychologists agree that if you have bipolar disorder, you should avoid alcohol and recreational drugs altogether. As I talk about in Chapter 5, alcohol and drugs interfere with the effects of your medication and worsen the course of your illness (for example, Sonne <Sr Brady, 1999; Strakowski et al., 2000). If you use alcohol and drugs, you are likely to become inconsistent with your medication regimen and will have more trouble becoming stable as a result (Keck et al., 1998; Strakowski et al., 1998). Worst of all, alcohol and drug use puts you at a much greater risk for committing suicide (Jamison, 2000b; see also Chapter 11).

Some doctors will tell you that you can drink alcohol in very small quantities (for example, a single glass of wine with dinner). There may be people with bipolar disorder who can do this and stay stable, but, to be honest, I know very few. I tend to take the more extreme view that not drinking at all and not using any drugs (including marijuana) is one of the best ways to maintain wellness. People with bipolar disorder are quite strongly affected—in terms of their mood stability and behavior—by even small amounts of certain substances (see Chapter 5). This is especially the case if they indulge in alcohol or drugs when their mood states are already starting to fluct

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