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
- Genetic vulnerability (necessary)
- Cyclicity/anniversary (sufficient)
- Major stressors (sufficient)
- Lack of support (sufficient)
- Lack of medication (necessary)
Factors Important for Triggering an Episode
- 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.
- 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
- 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
- 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
- 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
Best Way to Avoid an Episode
The best way to avoid an episode is to learn well from the first
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
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
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:
- Giving feedback regarding patient's thinking, mood and behavior.
- Calling patient's doctor to arrange an appointment or to discuss
- Modifying the living situation to reduce stimulation.
- Providing consistent, structured, and support reassurance.
When You Notice Hypomanic Symptoms in Your Family Member or Friend
- Remain calm; do not panic or criticize.
- 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.
- 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
- Make positive suggestions to:
- Review activities and decrease schedule by one-third for at least
- Reduce stimulation (loud music, noise, light, talking, violent
movies, etc.) Enforce a QUIET environment (no visitors or
celebrations). Maintain planned, low-key days.
- 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.
- Monitor medication intake. Increase medication with doctor's
approval. Get serum level if on lithium, and make appointment to see
- Reassure patient that if he follows these steps, in 72 hours the
episode may be aborted.
- Be positive in attitude and actions. Use your sense of humor.
- 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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