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Spotting Icebergs From Miles Away: How to Use Early Warning Signs in Bipolar Disorder Relapse Prevention

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This is the first part in a 3 part series. We recommend reading them together.

I recently watched a documentary called “Titanic’s Final Mystery.” It put forth a new theory that, due to unusual weather conditions on the night of the Titanic tragedy, there was a mirage that prevented the ship’s lookouts from seeing the infamous iceberg. It’s an interesting theory, though there’s debate as to whether it’s true. But the bottom line is that due to a number of factors – including a belief that the ship was “unsinkable” and a failure to heed warnings – nobody spotted the iceberg in time to slow down the ship and avoid a collision.

Managing bipolar disorder is a little like navigating the cold, icy waters of the North Atlantic. Just as every ship is at risk of hitting an iceberg, every person with bipolar disorder is at risk of relapse into another mood episode (depression, mania, hypomania, or a mixed state, depending on the specific condition).The potential to “hit an iceberg” of relapse is just the nature of the illness. The good news is that relapses generally don’t appear out of nowhere – there are early warning signs that, with mindfulness and insight, allow you to spot an approaching mood episode in time to avoid being blindsided.

Relapse prevention has 3 parts:

  • Identifying and spotting early warning signs
  • Understanding potential triggers and vulnerabilities
  • Using management strategies (prevention and timely intervention).

I’ll be covering each part separately in this and my next two posts. I’m writing from the perspective of a psychotherapist who has managed bipolar I disorder well for many years. These posts are aimed at adults who are in treatment, relatively stable, and are aiming toward a high degree of recovery (if you aren’t familiar with the recovery concept, SAMHSA’s Working Definition of Recovery is a good place to start).

Why are early warning signs important?               

The importance of early warning signs is that the sooner you notice a potential problem, the easier it is to address. A mild symptom or two can often be addressed with a slight change of course – maybe calling a friend or going for a walk. A full-blown mood episode, on the other hand, may require a sudden veer into hospitalization or months of intensive treatment. When you can spot warning signs way ahead of time, it’s possible to prevent symptoms from getting worse – and avoid a big wreck.

The period that precedes a mood episode is known as the “prodromal phase.” The word prodrome comes from the Greek for “running before.” So you can think of prodromal signs as messengers running up to warn you of what might lie ahead. It’s not until you have a whole cluster of symptoms at the same time that you have a mood episode “syndrome” (Greek for “running together”).

What types of warning signs should I look for?

Specific warning signs vary from person to person, although some (such as sleep changes) are fairly universal. Early warning signs can include:

  • Symptoms of bipolar disorder, possibly in a milder form (it’s worth noting that some symptoms may be residual or “subsyndromal” rather than prodromal – in other words some symptoms “hang around” between mood episodes but are not in and of themselves warning signs)
  • Symptoms of other (“co-occurring”) mental health disorders (sometimes co-occurring disorders “co-travel” with mood episodes, and sometimes they travel alone)
  • Behavioral signs such as isolating yourself or neglecting household chores
  • Changes in how you’re thinking or feeling
  • Physical symptoms such as digestive problems or headaches that don’t have another medical cause.

Here are some specific examples of warning signs:

  • Sadness or crying spells
  • Loss of pleasure in activities you normally enjoy
  • Decreased or increased energy
  • Anxiety or agitation
  • Anger or irritability
  • Appetite or sleep changes
  • Trouble with concentration or attention
  • Changes in thinking (e.g., racing thoughts, clouded thinking)
  • Trouble with work or other daily activities
  • Neglecting household duties (e.g., cooking, housekeeping, paying bills)
  • Feeling overwhelmed or like you need help
  • Desynchrony (feeling out of sync with your environment and other people).

I’ve also created a list of 100 Possible Warning Signs of a Bipolar Disorder Mood Episode, though even this list isn’t complete. Some signs are highly individual or quirky – like maybe you visit a particular website over and over, or spend lots of money on art supplies.

How do I become aware of my early warning signs?

Using warning signs for relapse prevention has 2 parts: identifying what your early warning signs are, and spotting them when they occur. It’s a learning process that requires time, effort, and persistence – but the payoff is well worth it. Here’s a basic guide:

1. Educate yourself on bipolar disorder.You don’t have to be an expert in order to identify warning signs, but you do have to understand essentials such as:

  • The types of bipolar disorder and which type you have
  • The symptoms of each type of mood episode that affects you (including the definition of each symptom)
  • The nature of bipolar disorder as a chronic brain condition that requires ongoing management.

2. Reflect on previous mood episodes. Think about prior mood episodes and try to recall what happened step by step. Try to remember what symptoms you had at these times:

  • When the episode was at its most severe
  • When it wasn’t quite as severe but was likely “past the point of no return”
  • When the earliest warning signs appeared.

I’ve developed a worksheet, Identifying Early Warning Signs From Prior Bipolar Disorder Mood Episodes,that can help you identify early warning signs after the fact.

3. Keep a mood chart: Mood charts give you a picture of what you’re experiencing each day, and can serve as a sort of “compass” to guide you away from relapse. They also allow you to record the medications you take and how much sleep you get. I religiously kept mood charts for 5 years (I don’t think I skipped a single day) – and I credit much of my recovery to that process. There are all kinds of tools available these days (phone apps, online tracking systems, etc.), but good, old-fashioned paper charts work just fine too. If you don’t know where to start, you can try this one from DBSA.

4. Develop mindfulness skills. Mindfulness has a variety of components and is an important skill to learn for all aspects of relapse prevention. In the context of warning signs, mindfulness helps you maintain awareness of your thoughts, feelings, and behaviors – which is critical for spotting warning signs. It also teaches you to stay in the present moment and not automatically react. That allows you to notice when something might be amiss, remain calm, and decide on the best course of action. Mindfulness can be aided by reminders in your environment – for example, you can write down your warning signs and put them somewhere you’ll see them regularly. I mentioned some mindfulness resources in a previous post.

5. Gain insight: In addition to maintaining awareness, you also need to evaluate your thoughts, feelings, and behaviors. This allows you to gain insight, which is where much of the power over bipolar disorder lies. One of the likely factors in the Titanic wreck was a lack of insight – everybody was so convinced that the ship was unsinkable that they failed to grasp the reality of the situation. A good way to gain insight is to have a regular “check-in” with yourself (say, daily or weekly). Sit down and reflect on anything unusual you’ve noticed that could be a warning sign. It helps to write things down – you can write entries in a journal, use a question-and-answer format, or just jot down some notes.

6. Learn to tell the difference between what’s “bipolar” and what’s “normal.” One of the most important reasons for gaining insight is to be able to make distinctions between early warning signs and “normal” behavior. This is one of the trickiest parts of navigating bipolar disorder. You have to be very honest with yourself – not downplaying thoughts, feelings or behaviors that could be problematic, and not overreacting to those that may just be a normal part of life. After all, everybody wakes up on the wrong side of the bed, gets down in the dumps, or loses their temper from time to time. While it can be helpful to err on the side of caution at first, over time you can learn to make these distinctions. There are 3 main things to reflect on:

  • Is the thought, feeling, or behavior in context?: Consider what’s happening in the larger context of your life, good or bad. Ask yourself if you’re having an  appropriate response of an appropriate size. Think about people you know who don’t have bipolar disorder – would they likely be experiencing the same thing, or not?
  • Is it characteristic of you?: Warning signs are generally out of character and differ from typical behavior. For example, I’m pretty quiet and introverted, so it would be out of character for me to start talking people’s ears off – and a surefire sign that something’s wrong. But for someone else, that might be their typical behavior and not an indication that anything is “off.”
  • Is it consistent?Throughout the course of a day, we have thousands of thoughts, feelings, and behaviors – including some that are negative, irrational, or strange. Most of them come and go and are no cause for alarm – it’s when they start lingering that there might be a problem. Take note of anything that seems unusual, and monitor it to see if a pattern starts to emerge.

7. Get help from others. It’s good to enlist the help of other “crew members,” including trusted friends and family members as well as mental health professionals. Loved ones may remember warning signs from prior mood episodes that you don’t. They can also help spot warning signs by acting as “another set of eyes.” Therapists can help you recognize your warning signs and develop a plan for responding to them (sometimes referred to as “prodrome detection therapy”). Therapists can also be particularly useful for helping you develop insight – since friends and family may not have the knowledge or objectivity to help you see things clearly.

8. Be on a constant lookout. Just as ships in icy seas need to be on the lookout for icebergs at all times, you need to make an ongoing commitment to watch for warning signs. That doesn’t mean you need to live in fear. It just means you need to be alert and cautious. Things gets easier over time (especially once you understand triggers, vulnerabilities, and management strategies, which I’ll cover in my next posts) – but to live with a high degree of recovery, you constantly need to watch the horizon for potential mood episodes.

With patience and persistence, those of us with bipolar disorder can learn to spot icebergs from miles away, stay safely afloat, and arrive at a destination of productive and fulfilling lives.

Comments

That was very helpful.Thank you

Thank you. All good info. I've been symptom free for almost 10 years, but recently am noticing some disturbingly familiar symptoms.

Thank you for sharing. I've been recently diagnosed and this has really helped me to develop a plan watch for signs. Thanks again!

Thank you for this insightful article. I have a 19 year old son who experienced a major manic episode last fall and needed to be hospitalized He's been on lithium since and has been stable. My concern is that he is planning a 500 mile hike in a month with a very close friend as a way to mark his completion of high school. He is exceedingly sensible and actively avoids alcohol and non prescribed drugs, partially due to fear of excascerbating bipolar disorder. He has had this trip planned for 3 years and had saved every penny from working to pay for it. I can't help feeling terrified that this is too soon but I'm aware that he needs to live his life and do not want to demoralize him by discouraging the trip or making him feel punished. I would like to ask how you manage in your own life, situations which might stress you physically or throw you out of mental or emotional synch. In short, is this a really bad idea??? Thanks so much. I'm grateful to find your excellent article.

I just came across your question when I was revisiting this article for another purpose. I can understand your concerns. I tend to believe in the “dignity of risk,” meaning people with disabilities should be able to make choices that allow them to discover their strengths and limitations on their own. So in that sense I don’t think the trip is a bad idea.

That said, I see several potential triggers, and since your son is so young he doesn't have a lot of experience managing the illness. I would hope the trip is carefully planned and that your son is open to changing the plan or cutting the trip short if necessary. I would want to ensure your son knows what warning signs to look out for, his friend is educated about what to look out for and what to do if things take a turn for the worse, and both are able to keep in contact with you on a regular basis. I would also talk with his prescriber about the potential impact of so much physical activity on his lithium levels and any other meds he is taking.

Very good information. It took years to get the correct diagnosis of bipolar II but since I know what I'm dealing with it I'm becoming more aware of my patterns and triggers. What is written above is what I try to practice daily.! I haven't had a major incident since last winter although I had a little bump in the summer it could of been worse if I hadn't become more aware, sought help and get on meds that really help. It's my first mood stabilizer and it makes life feel more normal. Also accepting this isn't going away but if I'm honest with myself it can be managed.

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