Bipolar disorder is one of the most difficult illnesses to treat because by addressing the depression part of the illness, you can inadvertently trigger mania or hypomania. Even in Bipolar II, where the hypomania is less destabilizing than the often-psychotic manic episodes of Bipolar I, persons often experience from a debilitating depression that can’t be lifted by mood stabilizers and antipsychotics. Antidepressants, though, can cause a person with bipolar to cycle between hypomania and depression.
I have worked with psychiatrists who were too afraid of cycling to risk using antidepressants for bipolar patients. They put me strictly on mood stabilizers and antipsychotics. However, I did not get well. I stayed depressed, and all original thoughts in my brain vanished. My current psychiatrist knows that depression is my primary threat, not so much the hypomania, so she was able to pull me out of the depression with the right combination of antidepressants, but is vigilant for any signs of hypomania. Because I know how vulnerable I am to hypomania, I have learned several strategies to help me stay grounded. By making them part of my life, I have been able to take less lithium, my mood stabilizer, which ensures that I continue producing original thoughts and not get too medicated. Here are 10 tools I use to avert hypomania.
1. Practice Good Sleep Hygiene
Developing good sleep habits is by far the most potent tool for preventing mania and hypomania. There are a handful of studies documenting that sleep deprivation is associated with mania and hypomania. By going to bed at 10 every night and sleeping a good eight or nine hours, we have the power to stop rapid cycling and to reverse mania or hypomania. In a study published inBiological Psychiatry a rapid-cycling patient was asked to remain on bed rest in the dark for 14 hours each night (gradually reduced to 10 hours). Times of sleeping and waking were recorded with sleep logs, polygraphic recordings, and computer-based event recordings. His sleep and mood stabilized when he adhered to a regimen of long nightly periods of enforced bed rest in the dark. The abstract’s conclusion: “Fostered sleep and stabilizing its timing by scheduling regular nightly periods of enforced bed rest in the dark may help to prevent mania and rapid cycling in bipolar patients.”
Good sleep hygiene means you go to bed at the same time every night, ideally before 10:30 p.m. — not one night 2 a.m. and another night 7 p.m.; you sleep at least eight hours a night; and you wake at the same time in the morning. Since many folks with bipolar disorder have sleep disorders, a nighttime routine is often needed. For example, I shut down my computer at 8 p.m. and try not to check my emails or messages on my phone. Reading a disconcerting email at 9 p.m. will keep me up all night. It takes me a good two hours to calm down, so I get out the lavender oil around 8:30 p.m., pull out a real book (not an iBook), and begin to tell my body it needs to seriously chill out.
2. Limit Your Screen Time
CNN did a story a few years ago on iPads (or LCD screens) and sleep. Journalist John D. Sutter asked Phyllis Zee, MD, a neuroscience professor at Northwestern and director of the school’sCenter for Sleep & Circadian Biology, if our gadgets can disturb sleep patterns and exacerbateinsomnia. Dr. Zee said:
Potentially, yes, if you’re using [the iPad or a laptop] close to bedtime … that light can be sufficiently stimulating to the brain to make it more awake and delay your ability to sleep. And I think more importantly, it could also be sufficient to affect your circadian rhythm. This is the clock in your brain that determines when you sleep and when you wake up.
I absolutely know that to be true, because for awhile, I was reading iBooks for a half-hour before bed and staying awake until 2 a.m. My concern with LCD screens isn’t limited to bedtime. I know from people in my depression community that persons with bipolar disorder have to be careful with LCD screens at all times, as they can make the highly sensitive person hypomanic if the person doesn’t take a break from them. For me and for many fragile persons with bipolar, looking into an LCD screen for too long is like keeping your light therapy sunbox on all day. I made the mistake of firing up that baby from 9 p.m. to midnight right after I got it, and I did not sleep one iota the next day, and felt hypomanic all day long. Keep in mind that not only is the light stimulating, but so is all of the messages and tagging and poking — especially if you have as many social media handles as I do.
3. Avoid Certain People and Places
Most of us have a few people in our lives that appear as though they’ve downed three shots of espresso every time we see them. They are usually great fun and make us laugh. However, the hyperactivity isn’t what you need if you haven’t slept well in a few weeks and are trying to calm down your body and mind. Same goes with places. I don’t dare step foot inside the mall, for example, between Halloween and New Year’s. There is just too much stuff being forced in front of my face. I also hate Toys-R-Us. I still have nightmares about the time my husband pressed three dozen Tickle Me Elmos and the entire shelf began to shake.
4. Pay Attention to Your Body and Breathe Deeply
Before attending the mindfulness-based stress reduction (MBSR) program modeled after the one developed by Jon Kabat-Zinn at the University of Massachusetts Medical Center, I did not pay attention to my body’s cues preceding a hypomanic episode. In fact, it was usually another person who would point out the embarrassing truth — like the time my editor wrote a letter to my doctor after I started publishing eight blogs a day thinking my traffic would go up. Now, though, when my heart races and I feel as though I have consumed eight cups of coffee, I know this is my opportunity to reverse my symptoms by doing lots of deep breathing exercises.
Of all the automatic functions of the body — cardiovascular, digestive, hormonal, glandular, immune — only the breath can be easily controlled voluntarily, explain Richard P. Brown, MD, andPatricia L. Gerbarg, MD, in their book The Healing Power of the Breath. They write:
By voluntarily changing the rate, depth, and pattern of breathing, we can change the messages being sent from the body’s respiratory system to the brain. In this way, breathing techniques provide a portal to the autonomic communication network through which we can, by changing our breathing patterns, send specific messages to the brain using the language of the body, a language the brain understands and to which it responds. Messages from the respiratory system have rapid, powerful effects on major brain centers involved in thought, emotion, and behavior.
5. Eliminate Caffeine
A good caffeine rush mimics hypomania. You feel more alive, more alert, like you could actually contribute something of worth to the world. That’s all fine and dandy except when you are teetering on the hypomanic edge. Caffeine can provide the ever-so-subtle push to the other side, especially if you aren’t sleeping well, which is when most people most crave caffeine. Stephen Cherniske, MS, calls caffeine “America’s number one drug” in his book Caffeine Blues because of the withdrawal our body goes through three hours after we’ve drank a cup of coffee or a Diet Coke. Persons with bipolar are even more sensitive to amphetamine-like substances that raise dopamine levels, so the safest way to prevent hypomania is to eliminate the stuff altogether.
My best workouts have been when I’m either on the verge of becoming hypomanic or when I am ticked off. My usual 10-minute mile goes down to an eight. I start passing people along my route, at the Naval Academy, feeling like Lynda Carter in her Wonder Woman getup. And my swim interval is consistent with the people who swam across the Chesapeake Bay in under two hours. The truth is I have averted many hypomanic episodes by working out until I collapse or at least become tired, which can take a few hours. Two years ago, the only way I was able to sleep was by swimming more than 300 laps a day. There are people for whom vigorous exercise triggers mania, but most experts report on the benefits of exercise for bipolar disorder.
7. Watch Your Sweets
There is a reason why ice cream, Swedish Fish, and animal crackers are comfort food for the bipolar person. The rush of insulin generated by those foods will calm those carbohydrate-craving brain pathways for a bit, until a crash in blood sugar has the person binging again on sweets. It’s a vicious cycle, one that can keep a bipolar person cycling indefinitely.
I will tell you a true story about sugar and bipolar. About 16 years ago, before I knew I wasallergic to sugar and that a high-carb diet was the worst thing I could do for my mental health, I would sometimes drink two bottles of Arizona Iced Tea and eat two or three chocolate-chip oatmeal bars for lunch. One day, there was a Horizon milk truck in front of our house with a large cow on the side. I started mooing at the cow. My new husband, behind me, was truly frightened by this and told me to lay off the Arizona Iced Teas and granola bars for awhile. I haven’t mooed at a truck since.
8. Be Careful With the Opposite Sex
I am all for good, healthy friendships between men and women. If you’re not bipolar. Consider me a prude, but I know how difficult it can be to be consistent with good boundaries if you are even the tiniest bit hypomanic. You sincerely didn’t mean for something you sent in an email to sound flirtatious — you were just being playful, like you are with your girlfriends. However, when you do get a reaction from a person of the opposite sex, something in the least bit flattering, that communication can ignite a rush that sends a signal throughout your entire body that you want more of the feel-good hormone it just experienced — dopamine, essentially. It’s even riskier if you have a history of substance abuse and bipolar — because your body will compromise any moral agreements you have signed off on prior to that email in order to get that damn rush again. If you’re not careful, this dangerous game will trigger a full blown manic episode. I have had the best intentions with 85-year-old men, and still, somehow, found myself in trouble. So for the time being, I’m sticking to female friendships.
9. Use a Shopping List
One of the most common manic behaviors is uncontrollable spending or shopping. Therefore, it is sometimes helpful for persons with bipolar disorder to make out a list beforehand of the items you absolutely need to buy — be it a grocery list, a Home Depot run, or a mission to get a your daughter’s friend a birthday gift. That way you won’t end up with 20 different kinds of paint swatches for the kitchen and living room you’ve decided to paint while you were at the store.
10. Allow Time to Decompress
This one is probably the second most important for me to prevent mania. I would say meditate, but that word produces too much expectation and pressure for me right now. Decompressing means after you finish something like a blog post or after you’ve forced yourself to be social for a few hours at a party that you didn’t want to attend, you allow yourselves 15 to 30 minutes to look at the ceiling fan in your bedroom and think about just that: the ceiling fan.
The case has been made that persons with bipolar disorder are creative and therefore need more chill time than the average person. Our brains are operating at a faster pace and more intensely than our non-bipolar friends for the periods of time where we must appear normal. So it is absolutely imperative that we allow some time where nothing is required — where we can drool, or lie in the grass, or doodle, or collapse in front of the front door. Although it seems as though these hours are unproductive, this activity will rebuild the gray matter of our brains and safeguard us from a manic episode.