This is the second article in a 3-part series. The blogger recommends reading the first article before reading this one. 

If you’ve been living with bipolar disorder for some time, you’ve likely noticed a connection between symptoms you experience and stressors in your life. Perhaps you can remember a specific stressor preceding your first episode. Stress plays a big role in initiating and maintaining the illness. By understanding stress and its connection to bipolar disorder, you can learn to get a handle on stress—and prevent it from leading to relapses.

The jury is still out on exactly how stress and bipolar disorder are connected, and the existing research is complex and contradictory. I’ve tried to simplify this information while maintaining as much accuracy as possible. My perspective is also informed by my own personal experience observing the relationship between stress and bipolar disorder over many years.

Why is it important to learn about stress management when you have bipolar disorder?

As I mentioned in my last post, managing stress is important for everyone—but perhaps even more important for those of us with bipolar disorder. Here are some reasons it’s essential to understand and manage stress:

• People with bipolar disorder are more prone to stress than the average person; they have more difficulty adjusting to and recovering from stressors.
• Stress can trigger symptoms and relapses, as I mentioned in a previous post on relapse prevention. When you’re experiencing stress, you’re more likely to become depressed, manic/hypomanic, anxious, or angry.
• If you get sick with a stress-related illness, the illness can become an additional stressor and make you more vulnerable to relapse.
• If you deal with stress through unhealthy behaviors, such as using drugs or alcohol, you become more vulnerable to relapse.

What role does stress play in causing bipolar disorder?

While nobody knows the precise cause of bipolar disorder, it’s generally thought to be some combination of biological and environmental factors. A widely agreed upon model for why some people get bipolar disorder and others don’t is called the diathesis-stress model. A diathesis is a predisposition or vulnerability, generally thought to be genetic.

According to the diathesis-stress model you need to have some level of diathesis, as well as some level of stress, in order to develop bipolar disorder. The stress may be biological, psychological, or social. It may include anything from a poor prenatal environment to abuse in childhood to stressful life events in adolescence or adulthood.

What role does stress play in contributing to relapses?

Again, stress can trigger mood episode relapses. It is by no means the only thing that triggers relapses, but it is a big one. This is good news—if relapses are brought on by stress, and you can manage stress, then you can at least to some degree prevent relapses.

As I mentioned in my last post, life events are a big source of stress and can be either negative or positive. There is some research on the role different types of life events play in contributing to relapses. Broadly speaking, it seems that negative events tend to trigger depression, and positive events tend to trigger mania/hypomania. However, it’s also possible for negative events to trigger mania/hypomania. For example, there’s a phenomenon known as funeral mania in which a person becomes manic shortly after a loved one dies.

Why are people with bipolar disorder more prone to stress?

In addition to inheriting a vulnerability to bipolar disorder, people with the illness may also inherit a vulnerability to experiencing stress more readily than other people. There are also a number of other reasons they may experience more stress than the average person. These include:

• Dealing with the stress of living with a mental illness: I mentioned in my last post that we experience stress any time we have to adjust or adapt, and that having an illness is a stressor. This includes bipolar disorder itself. Stress can come from multiple sources. First, you have to adjust to the diagnosis and the reality of having a chronic illness. Second, you have to make changes in things like lifestyle, career, and relationships in order to live successfully with bipolar disorder—and continually adjust and adapt based on your current circumstances. Finally, mood episodes themselves can cause stress. They may involve, for example, hospitalization, time off from work, or added financial burden.

• Interpreting experiences as stressful: People with bipolar disorder have a tendency to interpret events as stressful that others may see as neutral or insignificant. They often have cognitive vulnerabilities such as perfectionism and self-criticism that lead them to interpret situations in maladaptive ways. A theory known as the cognitive vulnerability-stress model attempts to explain mood disorders through the interaction of these cognitive vulnerabilities with stressful life events.

• Unintentionally contributing to the creation of stressful events: Research has shown that people with bipolar disorder experience more negative events than the average person throughout the lifespan. Part of this has to do with what’s called event generation. That means they may create stressful life events due to their own thought or behavior patterns—for example, they may inadvertently contribute to relationship breakups or job loss.If you recognize this in yourself, it’s important not to go into self-blame. The point is to become more aware of patterns that cause problems and work on them to the extent that you can.

• Prejudice and discrimination: It’s stressful to live with a stigmatized condition that many people don’t understand. The stress can take many forms—for example, deciding whether to disclose or not to disclose, figuring out timing and wording when you choose to disclose, and dealing with people’s reactions when they find out you have a mental illness. Another source of stress is being in an ongoing situation in which you know you can’t disclose without negative repercussions. I once worked for a supervisor who repeatedly made negative comments about people with bipolar disorder (I hadn’t disclosed my illness). That was an extremely stressful position to be in.

• Sensory overload: Many people with bipolar disorder are sensitive to noise and other sensory input. They may have deficits in sensory gating, the ability to block out unnecessary sensory information. There isn’t much research on this yet, although it may be due to differences in their brains. In any case, sensory overload can be very stressful.

How does stress lead to relapses?

I’ve talked about some of the reasons people with bipolar disorder may be more vulnerable to stress. But what exactly leads from stress to relapse? There’s no clear answer at this time, but there are a variety of paths that might be at play. Considering these paths is important because they suggest opportunities for relapse prevention. Here are some of the specific ways stress may contribute to bipolar disorder symptoms:

• Sleep loss and interruptions: This probably goes without saying, but stress can cause problems with sleep. Sleep difficulties from stress often take the form of insomnia, although they can also take the form of hypersomnia (excessive sleep) or disruptions in normal sleep architecture (the patterns of different types of sleep people need over the course of a night to be well rested). Sleep difficulties can lead to relapse.

• Disruptions in schedule: Stress often involves interruptions in schedules and routines. It may contribute to disruption of social zeitgeibers. These are cues that help people bring a regular biological and social rhythm to their days—for example, times for waking, sleeping, eating, working, and socializing. Disruption of these rhythms can lead to relapse.

• Poor self-care: During times of stress, people often neglect and stop taking care of themselves. They may miss meals, eat lots of junk food, or stop healthy habits such as exercise or social activities. The resulting poor nutrition, sedentary behavior, or lack of social support may contribute to relapse.

• Rumination: Rumination has been shown to prolong stress and to lead to depression. If you experience something stressful and are able to let it go, it probably won’t have much impact. But if you continue to replay it in your head, you will continue to experience stress. The brain is not very good at telling the difference between real and imaginary experiences—so it will assume you are still being exposed to the stressor and react accordingly. There’s also a related process known as basking, which involves ruminating on positive events. It’s possible that basking can lead to mania/hypomania.

• Social isolation: As I mentioned in my last post, one of the factors that makes stress worse is a lack of support. Social isolation is also a big factor in relapse. If you go through a big stressor without support, you’re likely to have a more damaging reaction to the stress—and you’re also more likely to relapse. A lack of support can be due to a genuine lack of social connections, but it can also be due to a tendency to react to stress by isolating yourself and not reaching out to others.

• Overactive or underactive response to events that involve goals or rewards: People with bipolar disorder may have a sensitive behavioral approach system (BAS). The BAS is a neurobiological system that helps regulate activities involved in attaining goals or rewards—for example, motivation, energy, and ambition levels.People with bipolar disorder may respond to goals and rewards more dramatically than other people. In the face of life events that involve being challenged to attain a goal or reward, including obstacles that provoke anger, people with bipolar disorder experience a BAS overactivation that can lead to mania/hypomania. In the face of life events that involve failures or losses, they experience a BAS shutdown that can lead to depression.

• Drug or alcohol use: As I mentioned above,using drugs or alcohol to cope with stress makes you more vulnerable to relapse. Substances might help you feel better in the moment, but in the long run they make things worse.

What is the body’s reaction to stress?

To learn to manage stress, it’s helpful to have some understanding of what goes on in the body. You don’t have to be an expert on anatomy and physiology, but it’s helpful to understand a little about the autonomic nervous system, the fight or flight response, and allostatic load.

The Autonomic Nervous System

The human nervous system is divided into two parts:

• The central nervous system, which includes the brain and spinal cord
• The peripheral nervous system, which includes the nerves attaching from the brain and spinal cord out to muscles, organs, and so on.

The peripheral nervous system is further divided into two parts:

• The somatic system, which controls voluntary processes like muscle movements
• The autonomic system, whichcontrols normally involuntary processes like heartrate, breathing rate, blood pressure, perspiration, body temperature, and muscle tension.

The autonomic system is the one we are concerned with in regard to stress. It is also divided into two parts:

• The sympathetic system, which functions to bring you into an activated state
• The parasympathetic system, which functions to bring you into a relaxed state.

The sympathetic and parasympathetic systems work together as a team to keep you in balance, or homeostasis. For example, the sympathetic system increases blood pressure, while the parasympathetic system decreases it.

The Fight or Flight Response

When we perceive a threat, an automatic survival response is initiated by a part of the brain called the amygdala. This is the fight or flight response, also known as the acute stress response. During this response, the sympathetic system goes into overdrive and the parasympathetic system takes a back seat.

The fight or flight response was originally designed to help us survive during life-threatening situations—say, a close encounter with a lion or tiger. During fight or flight:

• Heart rate, breathing rate, and blood pressure go up
• Blood leaves the extremities and pools in the middle of your body
• Muscles get tense and ready for action
• Perspiration increases.

Your brain also signals a variety of other systems to help you take immediate action. It releases a cascade of stress hormones known as glucocorticoids, the most well-known being adrenaline and cortisol. These hormones facilitate the stress response and later help return your body to homeostasis. Body functions that aren’t important for immediate survival, for example digestion and reproduction, go offline.

Once the source of stress has ended, the parasympathetic system is supposed to kick in and return you to homeostasis within a short time. This is known as the relaxation response. The only trouble is, it doesn’t always happen. Animals in the wild are much better at shaking off stress once a threat is over. We humans tend to do things like re-experience the stressful event in our mind, worry it will happen again, or stay on constant guard.

Allostatic Load

While the acute stress response is an important survival mechanism and critical in certain situations, if it continues over time it can lead to a host of health problems. This is due to allostatic load. Allostasis involves the things your body does to try to return itself to a state of homeostasis. Under chronic stress, your body works overtime to do this and damage can occur. For example, the release of glucocorticoids I mentioned above is helpful in the short run, but if those hormones remain elevated they can cause serious health problems. Allostatic load refers to “the wear and tear on the body” from the body’s prolonged response to stress.

What differences do people with bipolar disorder show in their bodies?

People with bipolar disorder tend to be more readily sent into the fight or flight state, and to remain in that state on an ongoing basis. In relation to other people, they have:

• An overactive amygdala
• Excessive sympathetic nervous system activity
• Decreased parasympathetic activity
• Increased glucocorticoids circulating through their systems.

Clearly, people with bipolar disorder are more vulnerable to stress than other people for a variety of biological, psychological, and social reasons. However, the message I want to leave you with is one of hope. There are all kinds stress management tools and techniques, some of which I’ll cover in my next post. By learning and practicing them, you can manage stress, prevent relapses, and improve your overall health.

Read more in the other parts of this series:

 

• The Basics of Stress 
• The Connection Between Stress and Bipolar Disorder
• Tools and Techniques for Managing Stress

You can find the rest of Carrie’s IBPF posts here.