Category: Bipolar Disorder

Values, Goals and Routine

15/10/2019

First published in Bipolar Life's newsletter on 15th October 2019

Photo by Emma Matthews Content Production on Unsplash

Have you ever looked back on the day and wished you had done more? Or have you experienced any difficulty sticking to a waking and bedtime routine? Both are common problems, and a lack of regular circadian rhythm may significantly affect bipolar disorder.

What is circadian rhythm?

The brain’s hypothalamus gland controls the organ systems of our body via hormones, or chemical messengers. A fall in light (such as during the evening) is detected by our eyes then affects a group of cells called the Suprachiasmic Nucleus (SCN), or ‘master clock’; this in turn causes an increase in production and release of melatonin, which makes us sleepy.

This process provides us with a circadian rhythm, which can be affected by altered bedtime and waking times, shift work and jet lag.

By the way, our circadian rhythm is just over 24 hours long, as in ‘circa’ nearly and ‘dian’ day and it is believed to have significant effects on body temperature, stress-hormone cortisol, even regulation of mood and body weight[1].

Why is circadian rhythm so important?

Dr Yoshikazu Takaesu[2] of Kyorin University, Tokyo suggests “…circadian rhythm dysfunctions may act as predictors for the first onset of bipolar disorder and the relapse of mood episodes” and therefore that “treatments focusing on sleep disturbances and circadian rhythm dysfunction in combination with pharmacological, psychosocial, and chronobiological treatments are believed to be useful for relapse prevention.”

In an article published in The American Journal of Psychiatry, Dr Allison Harvey[3] states that a high proportion of people with bipolar disorder are symptomatic between episodes; even in those receiving medication and psychological treatment. In particular, sleep disturbance affects quality of life and increases risk of relapse. She also suggests that daytime mood regulation can affect sleep and vice versa.

Dr Harvey also explains that it seems sleep disturbance escalates just before an episode and worsens still further during an episode. Although there appears to be an association, it is difficult to conclude from studies whether sleep disturbance is simply a feature of bipolar disorder, or a trigger for relapse.

How much sleep is enough?

A regular sleep/wake schedule of roughly eight hours sleep a night, seven day a week is proven to help protect against relapse, according to Dr Ellen Frank[4], Professor of Psychiatry and Professor of Psychology at the University of Pittsburgh School of Medicine, Pennsylvania. She explains that many people with bipolar disorder are late chronotypes (as are their relatives), which essentially means you sleep later and wake later than the average person. Dr Frank suggests if you can work your schedule around your chronotype, this could give you the most restful sleep but then make sure to stay on that schedule.

How can we optimise our circadian rhythm?

In the world of chronobiology, “zeitgeber” (German for “synchroniser”) is an external cue that affects the body clock, such as light alerting us to the time of day. Early research by physiologist Jürgen Aschoff found that social cues such as mealtimes or work schedules can also act as zeitgebers[5]. Dr Ellen Frank recommends having three to four smaller meals per day to help keep mood and energy levels stable[4].

The zeitgeber theory suggests that episodes of depression and mania or hypomania arise as a consequence of life events: a life event disturbs social zeitgebers such as mealtimes and bedtimes, and these changes then derail the circadian rhythm, triggering relapse[5].

A treatment based on this idea, called “interpersonal and social rhythm therapy” (IPSRT), has been shown as effective in reducing relapse in bipolar disorder[3]. Several studies[6,7] have shown that social rhythm therapy benefits people with bipolar disorder when added to medication.

As well as improving our circadian rhythms, having some sort of routine can assist us in setting and reaching time-based goals, which can improve mental health. For instance, small manageable goals can help lower stress from overwhelm and reduce unhelpful procrastination.

How do we end up with poorly structured days?

Routine can be disrupted through illness, whether it be physical or bipolar disorder. This can cause a multitude of symptoms such as poor motivation, low or excessive energy, low/high/unstable mood, poor concentration, and other problems with cognition such as difficulty with judgement and planning.

Life events such as loss of job, loss of regular social contact or interpersonal problems can also upset our balance.

Unhelpful thought processes where we over-identify with our thinking, known as cognitive fusion, can make it difficult to move forwards to a helpful behaviour. Examples might include: “I’m too lazy to do X” or negative thinking like “I’ll never get through everything I need to do. Might as well give up now” or “I don’t think I’m up to doing job Z perfectly so there’s no point.”

It is common human behaviour to experience habitual leaning towards ‘avoidant’ behaviours which usually make us feel better in the immediate moment (e.g. binge-watching TV or drinking excessive amounts of alcohol); unfortunately these avoidant behaviours are performed in place of healthier actions that could build our self-esteem and self-confidence because they follow our true values (e.g. going for a daily walk to improve physical/mental health, making sure to have a daily shower to practise self-care).

However, the thought of building a healthy, meaningful routine for ourselves can sometimes feel overwhelming.

Let’s look at some recommendations in line with Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy[8] (ACT), where discovering and continually reviewing our personal values can help us to set useful personal goals.

What if I’m struggling to make changes?

Behavioural activation is an evidence-based treatment and maintenance therapy. It is one part of CBT and is used in mood disorders to increase a person’s positive behaviours and reduce negative ones.

Here’s an example of a negative behaviour cycle:
Sleep in for hours to avoid facing a task –>
Feel groggy and poorly motivated with low mood –>
Fell less able to perform the task –>
Experience low mood, motivation and feel guilty and frustrated –>
Sleep in late again.

On the other hand, a person making a conscious effort to perform a positive behaviour (even if they don’t feel very motivated and aren’t enjoying it) will usually find that when the goal has been achieved, their mood, motivation and confidence improve, making it easier to continue positive behaviours.

In addition to behavioural activation, it can help to explore our own values, in order to set meaningful goals.

Photo by Greg Rakozy on Unsplash

Values & how they can help us set goal-orientated actions

Identification of values helps us work out our personal wishes and motivations, regardless of expectations from other people or society.

It is important to note that values are not describing our internal states (thoughts, feelings and emotions) as it would soon become clear that having a value of wanting to be happy and to always have positive thoughts would be impossible. Values are also not descriptions of how others behave towards us, as that is another thing we don’t have a great deal of control over either e.g. I want to be loved by person X.

By seeing where our current actions are aligned with our values, we are more confident in continuing and strengthening those actions. On the other hand, where we are not heading towards a value we feel is important, this can help focus our efforts. And if we are feeling ‘stuck’ and unsure as to what our values are, it can stimulate a thinking process to move us forwards.

We can prioritise the goals which will lead us to values we find most important. They can help us with time management. For instance, we may decide that initially we need to set aside ten minutes a day on a goal.

It’s also useful if we can keep an open mind for what comes up for us when we plan a goal or are actioning the goal. For instance, we may need to deal with negative thinking like “this needs to be perfect or there will be consequences” or cognitive fusion like “I’m too lazy to do Y”. Or we might spot potential barriers and decide how to work around them.

Some examples of personal values include

Creative values e.g. to be imaginative, resourceful
Experiential values e.g. to appreciate beauty in art, music etc., to love wholeheartedly
Attitudinal values e.g. to be accepting of myself, to be accepting of others, to be fair, to be appreciative of things I have in life, to be open-minded
Relationship values e.g. to be caring towards my partner/spouse, to bring up my child in a responsible manner, to be a loyal friend
Achievement values e.g. to work hard, to improve my knowledge and skills
Recreation values e.g. to regularly timetable leisure activities
Health values e.g. to improve physical fitness, to look after mental health, to live life in a way that brings me spiritual meaning (e.g. regularly practising gratitude and patience, yoga, volunteering)

For a list of many more possible values, you could look at the ‘Card Sort’ exercise[9] for inspiration and ideas.

From identifying which values are most important to you, and ones that could benefit from more attention, you have a starting point from which you can begin to set meaningful goals. You might simply categorise your values into Very Important all the way through to Not Important, or just choose the 5-10 most important to you today. As with all things, they are subject to change so review them when you feel ready.

Be SMART

The SMART acronym apparently first appeared in 1981 in Management Review. Since then, SMART has been used by a tool by countless organisations and individuals to help people identify and reach their goals. There are a few different versions, but we will use a commonly used one for the purposes of the article.

Don’t forget that we may need to break down a single goal into smaller ones, and more than one goal can run at the same time, so write down your ideas and plans.

To make sure your goals are clear and reachable, each one should be:

Specific (who is involved, what do I want to achieve, where will it take place, why this goal)
Measurable (how many/much or another indicator of success).
Achievable (do I have the resources and capabilities).
Realistic (is this sensible, do I have the motivation to commit to the goal). This one is especially important as people in a depressive phase might be more likely to set very low goals, and those in hypo/mania may set unrealistically high goals)
Time bound (when do I wish to achieve this goal)

Reward yourself for completion of a goal if that helps, as some tasks are an effort and not always enjoyable.

Of course, setting and achieving goals is not always straightforward. Don Kattler[10], a peer researcher for The Collaborative RESearch Team (CREST.BD) recommends that if you find yourself unable to reach a goal, first practise self-compassion (for instance “struggling to achieve is the human condition”, “I’m doing the best I can”), kindness and non-judgement. Next you could gently investigate any internal (e.g. feeling tired) and external barriers (e.g. insufficient time) that got in the way of success this time. Problem-solving an issue increases your chance of success next time. Another realisation might be that the goal was unrealistically high, so you might reduce the difficulty of the goal to maximise success.

And finally, don’t forget you can also check in with friends, family, your GP, psychiatrist or psychologist to if you need more support.

References

1. National Institute of General Medical Sciences. 2019. Circadian Rhythms. [ONLINE] Available at: https://www.nigms.nih.gov/education/pages/factsheet_circadianrhythms.aspx. Accessed 10 October 2019].

2. Takaesu, Y., 2018. Circadian rhythm in bipolar disorder: A review of the literature.. Psychiatry and Clinical Neurosciences, [Online]. 72(9), 673-682. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29869403 [Accessed 10 October 2019].

3. The American Journal of Psychiatry. 2008. Sleep and Circadian Rhythms in Bipolar Disorder: Seeking Synchrony, Harmony, and Regulation. [ONLINE] Available at: https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2008.08010098. [Accessed 10 October 2019].

4. DBSAlliance. (2019). Treatment Choices: Options for Bipolar Disorder. [Online Video]. 2 December 2014. Available from: https://www.youtube.com/watch?v=gzgi9Sr7twY&t=1137s. [Accessed: 10 October 2019].

5. Association for Psychological Science. 2016. Controlling Mood Disorders: A Matter of Routine. [ONLINE] Available at: https://www.psychologicalscience.org/observer/controlling-mood-disorders-a-matter-of-routine. [Accessed 10 October 2019].

6. Frank, E., 2005. Two-Year Outcomes for Interpersonal and Social Rhythm Therapy in Individuals With Bipolar I Disorder. Archives Of General Psychiatry, [Online]. 62(9), 996-1004. Available at: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1108410#26048444 [Accessed 10 October 2019].

7. National Institute of Mental Health. 2007. Questions and Answers About the STEP-BD Depression Psychosocial Treatment Trial. [ONLINE] Available at: https://www.nimh.nih.gov/funding/clinical-research/practical/step-bd/questions-and-answers-about-the-step-bd-depression-psychosocial-treatment-trial.shtml. [Accessed 10 October 2019].

8. ACT Mindfully. 2019. Acceptance & Commitment Therapy. [ONLINE] Available at: https://www.actmindfully.com.au. [Accessed 10 October 2019].

9. William Miller, University of New Mexico, (2019), Personal Values Card Sort [ONLINE]. Available at: https://www.guilford.com/add/miller2/values.pdf?t [Accessed 10 October 2019].

10. Don Kattler, Collaborative RESearch Team to study Bipolar Disorder, UBC. (2015). CREST.BD Home & Bipolar Disorder Slides. [Online Video]. 6 March 2015. Available from: https://www.slideshare.net/crestbd/crestbd-home-webinar-slides. [Accessed: 10 October 2019].

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Stigma and Bipolar Disorder

24/9/2019

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First published in Bipolar Life's newsletter on 17th September 2019

Image by Free-Photos from Pixabay

Why should we care about stigma?

Stigma affects many people in society, from race and gender inequality through to people living with mental health problems like bipolar disorder. It is a huge issue with myriad consequences, not least that individuals may experience knock-on effects of stigma that can even outweigh those of the mental health disorder itself. By extension, family and friends may also experience stigma, also known as ‘courtesy’ or ‘association stigma’.

How might an individual be affected by stigma?

An individual experiencing stigma may form negative attitudes and behaviours about him or herself (self-stigma), and may:

be less likely to acknowledge and recognise illness
be less likely to seek, accept or complete treatment
have reduced self-esteem and self-efficacy
have more problems at home
have more problems with employment
have more problems socially, in turn leading to isolation. An individual might notice friends and family withdrawing, or alternatively being overbearing / patronising, or not believing in his or her abilities.

Isn’t stigma decreasing?

Despite the globally large number of public campaigns, high school education and media coverage about mental health, one might think that stigma would be less prevalent. However, according to the General Social Survey which collects data about U.S. residents, the public is in fact more stigmatising – despite increased knowledge about mental illness – than back in the 1950s.

The reasons for this surprising worsening of public opinion include:

Exposure to the public of high numbers of people with untreated mental illness
Lack of strict regulation on media portrayal of the mentally ill, such as over-emphasis on diagnosis in violent crime reports, use of prejudicial words such as “crazy”, inaccurate representation of mental illness in film (a study of various horror films concluded, “Homicidal maniacs are the most common stereotypes. Misinformation is often communicated. Familiar horror tropes are used to stigmatize mental health care environments.”
Stigmatisation and trivialisation of mental illness such as the common use of terms like “schizo”, “psycho”, inaccurate self-description as “bipolar” for normal mood swings or “depressed” for being simply sad.

What is stigma?

Ostracisation of members of society has existed as far back in history as ancient Greece. For example, in Athens, traitors and slaves were physically branded with ‘the mark of shame’ – ‘stigma’ in Greek.

Nowadays stigma is less visible, but most affected are those with mental illness, the homeless, and substance abusers. In one study, it was found that although people with bipolar disorders 1 and 2 experienced the same personal experience of stigma as those with unipolar depression, the impact (in terms of quality of life, social and familial relations and self-esteem) was much worse in people with bipolar disorder.

Stigma can include one or more of the following:

Stereotyped thinking (through ignorance or misinformation)
Prejudice (emotional response e.g. disgust, negative attitude)
Discrimination (behavioural response)
Globalising (generalising about the whole group an individual is deemed to be part of)

A survey by the Royal College of Psychiatrists in the U.K. looked at public perception of people with severe depression. The most commonly held beliefs were that these people:

Were unpredictable (56%)
Were unable to recover, even with treatment (23%)
Were dangerous (23%). This is disappointing as studies show people with mental illness are in fact more likely to be victims than perpetrators of violence.
Could pull themselves out of it (19%)
Had only themselves to blame (13%)

Dr Kay Redfield Jamison, Professor of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, U.S.A. is well known for her work on bipolar disorder as well as her autobiographical account of her own experience of the condition. She states that these study figures are even higher when applied to people with bipolar disorder.

It is possible bipolar disorder may appear unpredictable due to its sometimes-fluctuating nature, depending on whether the individual is relatively well and getting treatment and support, or experiencing a period of depression, mania or mixed state.

A little more about self-stigma

It is not uncommon for an individual with bipolar disorder to experience negative beliefs about him or herself, which may reduce self-esteem and self-confidence. Worse still, this state of mind may lead to avoidant behaviours like not pursuing opportunities, or not challenging negative self-beliefs by gathering evidence to the contrary.

Even within the medical profession there is stigma from, and towards, other healthcare providers. Compassion without sufficient knowledge may be a contributing factor in some cases.

Dr. Jamison offers an interesting observation that the ‘silently successful’ get well because they have sought and received good care, yet they remain silent for fear of personal or professional reprisal. This in turn perpetuates the public’s misconception that the mentally ill don’t get better.

Where to from here?

Fortunately, clinicians and researchers in many countries are increasingly aware of the rise of stigma and driving ongoing important work in this field. Though there is no one simple solution, here are some helpful, evidence-based suggestions for moving forward.

A Canadian study recommended six approaches to stigma reduction:

Education
Protest
Contact-based education
Legislative reform
Advocacy
Stigma self-management

Education could be directed at the public or specific groups such as within schools or the workplace. Protest could be in the form of formal objection to stigmatising individuals or groups. Contact-based education has been found to be particularly useful, where a member of the public hears the personal story of someone with mental illness; this person should be doing well and be successfully managing their condition. It is not necessary for the contact to be in person, and could be via an online video, though this may be less effective. Stigma self-management should include education (for example peer-supported self-learning and recovery-orientated supports and services).

Individuals, friends and family

On an individual level, it should be noted that self-stigma can manifest and be managed in different ways. In CREST.BD's Stigma123 Webinar, Natasha Kolida, a student and researcher with bipolar disorder, encourages education as well as being holistic and self-compassionate in one’s journey. More about CREST.BD in a moment.

Dr. Jamison advises:

Patients and family members should be aware of their political strength as they make up a large percentage of voters.
There needs to be more work with medical and mental health communities, including open discussion and change. In particular, work needs to be done in the area of medical care for health care providers, who currently risk penalties in disclosure that are often not in keeping with their quality as practitioners.
Public campaigns should be on a more positive note, with more emphasis on neuroscience research and the benefits of treatment.

In 2014 Dr. Roumen Milev, Professor of Psychiatry and Psychology at Queen’s University, Canada ran a CREST.BD webinar about overcoming stigma in bipolar disorder. In this presentation, he describes a fascinating community-based recovery-orientated course provided to 8-10 participants with mood and anxiety disorders. Comprising seven closed two-hour sessions, content included education about stigma (covering self-stigma, family, friends and medical settings; education, housing and the workplace); some sessions taking the form of group workshops with brainstorming and role play.

Perhaps this is the sort of course we could make widely available in Australia to complement our current inpatient and community programmes for those with bipolar disorder.

Who is CREST.BD?

CREST.BD describes itself as “The Collaborative RESearch Team that studies psychosocial issues in Bipolar Disorder...CREST.BD is a multidisciplinary collaborative network of researchers, healthcare providers, people living with bipolar disorder, their family members and supporters.” Bipolar Life’s patron, Professor Greg Murray, is Deputy Lead and a key researcher with this inspiring international team.

CREST.BD’s website includes excellent resources and tools including videos on stigma, cognition, sleep, mood, physical health, home, self-esteem, leisure, relationships, spirituality, money, independence, identity, work and study for people with bipolar disorder.

Media and beyond

Finally, looking at how we can make a difference on a larger scale, StigmaWatch is a constructive program run by national mental health charity, SANE Australia. Its aim is to promote responsible reporting of mental illness and suicide in Australian media and is supported by Mindframe, an Australian Government initiative. This is a great example of protest being used as a tool to improve public perception of mental illness. SANE encourages anyone to report to StigmaWatch if they see inaccurate or inappropriate terminology or reporting of mental illness or suicide.

SANE’s website states that “Mindframe has also developed resources for media professionals, journalism students, scriptwriters, police and courts, and conduct briefing sessions with media organisations to discuss issues relating to mental illness and suicide”.

Conclusion

With so much research and an increasingly evidence-based approach to combating stigma, individuals have more power than ever to influence how bipolar disorder is seen in society. In addition, the many tools available can greatly assist an individual to reduce self-stigma and embrace life more fully.

References

YouTube. 2019. Discrimination and Stigma Against Patients with Depression and Bipolar Disorder. Johns Hopkins Medicine. [ONLINE] Available at: https://www.youtube.com/watch?v=9Hc0NF89ryg. [Accessed 17 September 2019].

YouTube. 2019. Bipolar Disorder Stigma, Suicide & Families. CRESTBD. [ONLINE] Available at: https://www.youtube.com/watch?v=_eE8YSSo-tA&t=1582s. [Accessed 17 September 2019].

YouTube. 2019. Overcoming Stigma in Bipolar Disorder: Challenges and Opportunities. CRESTBD. [ONLINE] Available at: https://www.youtube.com/watch?v=yDJ4DSZ0Id0&t=2258s. [Accessed 17 September 2019].

YouTube. 2019. CREST.BD's Stigma123 Webinar Jan2016. CRESTBD. [ONLINE] Available at: https://www.youtube.com/watch?time_continue=234&v=LKkpvPD903Y. [Accessed 17 September 2019].

Goodwin, J., 2014. The Horror of Stigma: Psychosis and Mental Health Care Environments in Twenty‐First‐Century Horror Film (Part II). Perspectives in Psychiatric Care, [Online]. 50/4, 224-234. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/ppc.12044 [Accessed 17 September 2019].

Arboleda-Flórez, J., 2012. From sin to science: fighting the stigmatization of mental illnesses.. Canadian Journal of Psychiatry, [Online]. 57(8):, 457-63. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22854027 [Accessed 17 September 2019].

CREST.BD. 2019. New directions in bipolar disorder research, treatment and care. [ONLINE] Available at: http://www.crestbd.ca/. [Accessed 17 September 2019].

SANE. 2019. StigmaWatch. [ONLINE] Available at: https://www.sane.org/services/stigmawatch. [Accessed 17 September 2019].

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The Write Action

Values, Goals and Routine

What is circadian rhythm?

Why is circadian rhythm so important?

How much sleep is enough?

How can we optimise our circadian rhythm?

How do we end up with poorly structured days?

What if I’m struggling to make changes?

Values & how they can help us set goal-orientated actions

Be SMART

References

Stigma and Bipolar Disorder

Why should we care about stigma?

How might an individual be affected by stigma?

Isn’t stigma decreasing?

What is stigma?

A little more about self-stigma

Where to from here?

Conclusion

References

Dr Alice Lam

Archives

Categories

The Write Action

Values, Goals and Routine

What is circadian rhythm?

​Why is circadian rhythm so important?

How much sleep is enough?

How can we optimise our circadian rhythm?

How do we end up with poorly structured days?

What if I’m struggling to make changes?

Values & how they can help us set goal-orientated actions

Be SMART

References

Stigma and Bipolar Disorder

Why should we care about stigma?

​How might an individual be affected by stigma?

Isn’t stigma decreasing?

​What is stigma?

​A little more about self-stigma

​Where to from here?

​Conclusion

References

Dr Alice Lam

Archives

Categories

Why is circadian rhythm so important?

How might an individual be affected by stigma?

What is stigma?

A little more about self-stigma

Where to from here?

Conclusion