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

A good detective uses a variety of methods to solve cases: paying attention, asking questions, making connections. Those of us with bipolar disorder can be “relapse prevention detectives,” investigating the mystery of what culprits are behind relapses. We can gather clues, examine evidence, and draw conclusions about which triggers and vulnerabilities cause trouble and put our recovery at risk.

The perspective I’m presenting is informed by cognitive behavior therapy (CBT) models, my own work as a therapist, and my own experience preventing relapses. I’ve simplified some concepts in order to present a clear and user-friendly guide. There’s no “agreed upon” understanding of triggers and vulnerabilities in this context, so you might find different viewpoints elsewhere.

What is a trigger?

Simply put, a trigger in bipolar disorder is anything that can potentially push you in the direction of a mood episode. Assuming you are stable, that would generally be anything that leads to early warning signs. If you already have some symptoms, it would be anything that worsens them. It often takes a number of triggers working together in a “conspiracy” to create a full-blown mood episode.

As I mentioned in my last post, relapses usually don’t come out of nowhere. Identifying the symptoms or behaviors that serve as warning signs helps you spot potential mood episodes in time to prevent them. Understanding what triggers mood episodes gives you an extra layer of power because it helps you understand where symptoms or behaviors come from.

What types of triggers are there?

Triggers vary from person to person, but there are a number of common ones that impact many people. Here’s a list of some of “the usual suspects”:

1.  Sleep loss: Getting enough sleep is essential when you have bipolar disorder. Changes in quantity or quality can be a trigger. Sleep loss itself can have dozens of different triggers, such as:

• Drinking caffeinated beverages too close to bedtime
• Travel and jet lag
• Poor sleep environment
• Hormonal fluctuations (such as those in PMS and menopause)
• Using a tablet or e-reader at night.

2. Stress: Any time we have to adjust or adapt, we experience stress. Stressors can be negative or positive. There are several different kinds of stressors, including:

• Life events such as getting married or divorced, starting or losing a job, having a child, or losing a friend or family member
• Daily hassles such as traffic, car trouble, bad weather, losing things, or getting unexpected bills
• Relationship difficulties or interpersonal conflict including arguments, criticism, rejection, pressure from others, and not getting your own needs met in relationships.

3. Social isolation: Spending too much time alone can be a trigger, since other people can:

• Provide emotional support and motivate you to do things that are good for your mental health
• Be another set of eyes to look for warning signs (as I mentioned in my last post)
• Give you an opportunity to help and contribute (which is good for mental health). 

4. Sedentariness: Exercise and movement help maintain mood stability – so being sedentary can be a big trigger. Keep in mind that exercise impacts people differently, so you have to find the right type and amount of exercise for you. Exercise can potentially trigger mania/hypomania in some people, and exercising close to bedtime can interfere with sleep.

5. Substance use: Substances are some of the most powerful triggers, since they can directly impact brain chemistry. Substances that can trigger mood episodes include:

• Alcohol
• Nicotine
• Marijuana
• Caffeine
• Other drugs, such as amphetamine and cocaine.

6. Structure insufficiency: Structure and routine are important when you have bipolar disorder. Biological and social rhythms help keep you stable. Schedule disruptions can also be triggers (such as holidays, special occasions, or time changes). Structure includes having regular times for:

• Waking and sleeping
• Eating meals
• Work or volunteer activities
• Exercise
• Social and leisure activities.

7. Self-care insufficiency: Lack of self-care decreases your resilience and can put you on the fast track to relapse. Self-care includes:

• Getting enough rest
• Taking breaks from work
• Having realistic expectations of what you can accomplish
• Eating healthful foods
• Getting enough water and fresh air. 

8. Seasonal changes: Some people are triggered during certain times of year. A classic seasonal pattern is an increase in depression in fall and winter, and an increase in mania/hypomania in spring and summer. However, you may find that you have a different pattern (or you might not have pattern at all).

9. “Stinkin’ thinkin”: Also called cognitive distortions, stinkin’ thinkin’ refers to thoughts that can potentially trigger mood episodes. Cognitive-behavior therapy addresses specific types of stinkin’ thinkin’, such as all-or-nothing thinking and jumping to conclusions. Although cognitive distortions are usually associated with depression, it’s also possible for thoughts that are “irrationally positive” to trigger mania/hypomania.

10. Sensory overload: Many people with bipolar disorder can be easily overwhelmed by their environments, or have difficulty filtering visual, auditory, touch, and other sensations. Here are a few examples of triggers some people report:

• Sunlight or bright lights
• Loud or high-pitched sounds
• Tight or uncomfortable clothing
• Crowded, noisy, or cluttered environments
• Trying to have a conversation when there is background noise (like at a party or in a crowded restaurant). 

Some of the triggers on this list might look familiar, since in my last post I mentioned a number of them as possible early warning signs. There can indeed be overlap between triggers and warning signs. For example, sleep loss, substance use, and social isolation can be early warning signs – but they can also be triggers. 

What is a vulnerability?

A vulnerability is a condition or behavior pattern that makes you more susceptible to triggers. Here are some examples:

• Perfectionism or high achievement expectations
• Self-criticism or low self-esteem
• Emotional reactivity (difficulty responding to emotional stimuli effectively)
• Impulsivity
• “Sociotropy” (being a “people pleaser,” being overly invested in relationships)
• “Autonomy” (having a desire to be independent and in control, disregarding feedback from others)
• Deficits in communication, decision making, or problem solving skills
• Thinking style that tends toward cognitive distortions (everybody has cognitive distortions at times, but some are prone to them as a pattern)
• Rejection sensitivity (expecting and easily perceiving rejection, taking actual rejection very hard)
• Untreated co-occurring disorders such as anxiety, PTSD, or alcohol use disorder. 

Vulnerabilities are important because they can help you understand the reasons you are experiencing certain triggers. Vulnerabilities and triggers are often “partners in crime,” working together to cause mood episodes. Here are a few examples:

• If you tend toward perfectionistic behaviors, you might experience a great deal of stress from a work task that wouldn’t be all that stressful for someone else.
• If you act from a place of low self-esteem, you might choose relationships that are full of difficulties or doomed to failure.
• If you have people pleasing tendencies, you might agree to go out with a friend to a noisy, crowded event that will last well past midnight – even though you don’t want to go and know there will be negative consequences.
• If you like to be independent and in control, you might not admit when you are stressed out and ask for help.
• If you have untreated PTSD symptoms, you might use drugs or alcohol to cope.

Fortunately, once you recognize a vulnerability, you can change it (although it will likely take some effort). I’ll talk more about that in my next post.

How do I become aware of my triggers and vulnerabilities?

Understanding your triggers and vulnerabilities has three parts:

• Identifying what yours are
• Noticing when you encounter them
• Anticipating when you might encounter them.

This is an ongoing process that requires careful detective skills: gathering evidence, noticing small clues, anticipating your perp’s next move. The guide I gave in my last post for becoming aware of early warning signs also applies here. I’ll go back over that guide, specifically as it relates to triggers and vulnerabilities:

1. Educate yourself. Learn what triggers and vulnerabilities tend to impact people. I’ve covered some of the major culprits, but my lists are by no means comprehensive. You can learn more by reading books and articles, attending a support group where you can learn from other people’s experiences, or participating in an online forum or discussion group.

2. Reflect on previous mood episodes. To help determine who your offenders are, think about prior mood episodes and try to remember all the factors that preceded them. What triggers did you experience? What vulnerabilities might have made the triggers more likely? You can also think about times you experienced an event or situation that would normally trigger you but did not. What was the difference?

3. Keep a mood chart. Mood charts help you make the connection between symptoms you’re experiencing and triggers that could be responsible. For example, if you rate your mood as more depressed than usual, you can do some detective work to identify potential suspects. Have you been skipping out on exercise? Have you been staying home by yourself a lot, rather than going out and interacting with other people? Could it be seasonal depression?

4. Develop mindfulness skills. Mindfulness helps you maintain moment-to-moment awareness, which enables you to notice when you are experiencing a trigger or acting from a vulnerability. It also allows you to stay one step ahead of offenders by predicting when they’re likely to strike next. If you’re not paying attention, you may overlook problems that you could either prevent or quickly put an end to.

5. Gain insight. As I mentioned in my last post, insight is critical to recovery. In the case of triggers and vulnerabilities, that means building awareness of cause and effect – of what you do, think, and feel, and what the result is. When you notice a symptom or behavior that might be problematic, try to identify the chain of events, including thoughts, feelings, and behaviors, that preceded it. I’ve created a simple worksheet, Identifying Triggers and Vulnerabilities in Bipolar Disorder, that can help get you started. 

In my experience, if you want to live with a high degree of recovery, you have to be honest and humble enough to recognize your limitations. You have to be willing to consider that certain things are likely to cause problems and might be best to avoid or minimize (like certain substances, types of environments, or kinds of people). And you have to be willing to take a look at long-standing patterns that it might be helpful to change – not in the spirit of self-blame, but in the spirit of self-awareness.

6. Learn which triggers to avoid and which to manage. While there are some triggers you can and should avoid, there are others that are just a normal part of life. Distinguishing between what’s “bipolar” and what’s “normal” means learning that difference. I recently completed a training in dialectical behavior therapy (DBT). The trainer, Lane Pederson, had a great line that stuck with me: “Life is full of triggers.” His point was that people need to learn to manage triggers, rather than just trying to avoid them. 

Stress is a good example. I’ve noticed that some people with bipolar disorder choose not to take on new challenges, like working or starting a relationship, because they want to “avoid triggers.” That isn’t always the wisest choice. You will likely experience stress from such events, as most people do – but that doesn’t necessarily mean you’ll end up having a relapse as a result.

I’m not saying you shouldn’t be cautious. It’s important to make informed decisions that won’t jeopardize your recovery. But by monitoring early warning signs and practicing management strategies, you can experience stress and still maintain stability. In fact, some stressful experiences can enhance recovery, as I wrote about in a previous post on finding work that works.

7. Get help from others. Understanding your triggers and vulnerabilities can be difficult. As with early warning signs, other people may notice ones you don’t. Others can also help you foresee problems you might encounter in certain situations – because we all forget or underestimate our triggers and vulnerabilities sometimes. If possible, get assistance from a mental health professional who can help you get to the bottom of the case. The right therapist can help you gain insight into triggers and vulnerabilities that might not be obvious to you or other people in your life.

8. Be on a constant lookout. It takes continuous detective work to uncover the culprits that contribute to relapse. Triggers and vulnerabilities don’t necessarily remain the same over time. New ones might surface and start causing trouble. And, as you grow in your recovery, others might be “rehabilitated” and not be a problem anymore.

You may not always be able to identify clear triggers or vulnerabilities, and that’s okay. You don’t have to do this perfectly. The important thing is to be persistent and stay on the case. Understanding your triggers and vulnerabilities is well worth the effort. It enables you to feel more in charge of bipolar disorder and less like a helpless victim at its mercy. It empowers you to make choices that support your stability. And it allows you to outsmart your offenders with a variety of management strategies – which I’ll cover in my next post.