How to Avoid a Manic Episode

Whether an episode occurs, when, for how long, and how severe it is depends to a large degree on factors that are within the control of patient and family. For an episode to occur, the following are necessary or sufficient:

  1. Genetic vulnerability (necessary)
  2. Cyclicity/anniversary (sufficient)
  3. Major stressors (sufficient)
  4. Lack of support (sufficient)
  5. Lack of medication (necessary)

Factors Important for Triggering an Episode

Periodicity
Many bipolar patients demonstrate a biological rhythm with impressive regularity with regard to mood swings. Cycles of hypomania and/or depression come with predictable occurrence. These tend to be seasonal; spring for hypomania and fall for depression, or summer for hypomania and winter for depression.

Anniversary
A significant event, usually an "exit" event -- a loss, such as the death of a significant person, a divorce, a major move, change or disruptions, or a previous episode makes one more vulnerable. The appearance of the episode is one way of dealing or not dealing with the psychobiologically remembered trauma.

Stressful Life Events
For some bipolar patients, positive events such as a marriage, graduation, promotion, and honors can be as stress-producing as negative events. For some patients, any major change or deviation from a well-ordered, stable routine may trigger biopsychological disequilibrium.

Belief Systems
The way you think about yourself and the world around you has a great deal to do with how you behave. If you believe a hypomanic episode is inevitable and that you have no control over it, chances are the episode will occur in the fashion you have prophesied. Many bipolar patients become victims of self-fulfilling prophecies, assuming little responsibility for modifying behavior that might prevent episodes from occurring. Many patients believe if they continue to take medication regularly, the medication alone will automatically prevent episodes from happening.

Recognizing Symptoms
If an episode is to be prevented, accurate knowledge of the symptoms of hypomania and depression are crucial for both bipolar patients and family members.

A Support System
There is increasing evidence that individuals who live in an emotionally stable environment or who have significant others available for support during times of stress or crisis have an overall healthier outcome.

Best Way to Avoid an Episode

The best way to avoid an episode is to learn well from the first one.

The hypomanic episode clinically presents a clearly recognized, well-defined syndrome. This consists of a cluster of symptoms that include pressured speech; increased, often purposeless activity; marked decrease in need for sleep and perhaps food; and a marked need for instant gratification, attention, and approval. Noticeable irritability and displeasure prevail.

Hostility and argumentativeness occur when the individual is thwarted. There is a need to expand and exaggerate all behaviors. Voices are louder, and the colors of clothing are brighter. There is more spending of money, letter writing, phone calling, travel, gift bestowing, and advice giving.

There is a marked lowering of inhibitions and a pronounced disregard for the rights and feelings of others. There is also increased risk-taking; for example, relationships with strangers are personalized at an inappropriate level and with little regard for social amenities.

How can an Episode be Prevented, Stopped, or Lessened Before Clinical Symptoms Occur?

When the patient is in a stable condition, it is MANDATORY to establish an oral contract that elicits his/her cooperation in permitting a trusted significant person to make an intervention. The patient grants the significant person PERMISSION to intervene to prevent an episode by:

  1. Giving feedback regarding patient's thinking, mood and behavior.
  2. Calling patient's doctor to arrange an appointment or to discuss treatment.
  3. Modifying the living situation to reduce stimulation.
  4. Providing consistent, structured, and support reassurance.

When You Notice Hypomanic Symptoms in Your Family Member or Friend

Please remember:

  1. Remain calm; do not panic or criticize.
  2. Make statements rather than ask questions such as, "Are you getting high again?" Instead, say something like, "You are wound up and seem preoccupied. Let's talk about it." If you meet resistance, don't push; remind patient of the contract.
  3. Discuss with patient the fact that he has a choice and options. He can choose to avoid an episode or allow it to escalate and run its course with the probability of hospitalization and the loss of many present gains.
  4. Make positive suggestions to:
    1. Review activities and decrease schedule by one-third for at least 7-10 days.
    2. Reduce stimulation (loud music, noise, light, talking, violent movies, etc.) Enforce a QUIET environment (no visitors or celebrations). Maintain planned, low-key days.
    3. Regulate sleep--no naps--stay off the bed until at least 10:00 p.m. and don't get up until at least 6:00 a.m.
    4. Monitor medication intake. Increase medication with doctor's approval. Get serum level if on lithium, and make appointment to see doctor.
    5. Reassure patient that if he follows these steps, in 72 hours the episode may be aborted.
    6. Be positive in attitude and actions. Use your sense of humor.
  5. Suggest to patient he has internal control to regulate his behavior and thereby alter his biochemistry.

When you have achieved success with this episode, congratulate yourself and the patient. Mark the date on the calendar and write down what you observed and what you did to modify it.

Taken from a paper by Dr. Julia Mayo, Chief, Clinical Studies, Department of Psychiatry, St. Vincent's Hospital

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9/3/2004