The lessons I’ve learned from past manic episodes can help prevent future relapses.
I’ve been living with severe bipolar I disorder for over fifteen years. I’ve had five full-blown manic episodes. That’s four relapses. After my first manic episode, I didn’t think I’d have another. It was horrible—the episode, the shock, and the aftermath. I wanted to forget and leave it behind as soon as I could. It was too painful to recall those memories. I told myself it was a one-time event and to move on.
I liked being hypomanic though. I wanted to be hypomanic—the optimal creative, energetic, and productive version of myself. I didn’t appreciate that the downside of hypomania for me was how quickly it could escalate into mania. I failed to learn from my first experience. If I had evaluated what had happened, I might have been able to prevent the relapses or at least better manage them.
After I had my first relapse, I didn’t still think it would happen again. After my second relapse, I had to accept that this was a reality of my illness. I knew that I had to avoid getting sick at all costs. I had to assess the damage and setback caused by each manic episode. It would take me no less than six months to recover from each hospitalization. To move forward with my life the relapses had to end. I relied on medication, my doctor, and my spouse to keep from slipping.
I walked a tight rope for years, pushing to live a fuller life while avoiding relapse. Sometimes, motivated by a cause or project, I would find myself fully engaged and energized. I could feel the hypomania surge. A few times, when no one else stopped me, I cycled up to the edge, then slipped past the point of no return and into mania. I relapsed, and the process would start over.
It was only after my fourth relapse that the key missing piece sunk in. I finally realized that I had to be the most active participant in my care. I also had to reevaluate my entire treatment. If my treatment better accommodated my creativity and drive, perhaps I wouldn’t crave the high of hypomania. I couldn’t rely only on my doctor and spouse to keep me in the safe zone. I needed to take ownership, but I also couldn’t do it alone. I still needed the right medical treatment and family support, but I needed to be the team leader.
Taking ownership required me to face my prior episodes. I couldn’t forget them. My relapses showed that I hadn’t learned from my experiences. The answer to preventing relapse was in studying and learning from my history of relapse. Below I summarize the process I followed to translate my personal history into a prevention plan. I’ve organized it as a series of steps which might help others learn from their mental health episodes to sustain recovery.
Step 1 – Review the past
Document what happened from the beginning to the end of the manic episode.
Create a time line that documents the occurrence of triggers, mood changes, and onset of symptoms such as behavior and sleep changes
Gather feedback from witnesses, such as your significant other, and doctors who observed the cycle
Collect evidence from these episodes, including notable emails and writings
Step 2 – Analyze the patterns
If you have experienced multiple episodes, evaluate the recurring patterns between them. This history will help predict and curtail new episodes. These are some of the patterns I observed in my episodes.
Prior to my triggers appearing, I was often in a state of deep depression
My triggers always involved issues of social injustice
Triggers manifested themselves in email missives, fixation on the news, religious preoccupation, dismissal of other people’s concerns
My main symptoms were racing thoughts and lack of sleep
Interests and habits became amplified to extreme levels. For example, lighting a candle from time to time morphed into lighting many candles all at once. An interest in saints intensified into religious preoccupation
I escalated very quickly from triggering events to symptoms and then mania
Step 3 – Develop rules based on the patterns
Identifying these patterns can help identify the onset of a new episode. Setting up rules of thumb based on history can help defuse or manage an episode. Below are a couple of the rules I developed.
If I experience any of the signs of hypomania, I should let my doctor and spouse know immediately
Having a sleepless night is a key sign of cycling up for me. I should contact my doctor who might adjust medication to help me sleep
Certain of my behaviors which became amplified when manic were OK in moderation, but should be monitored. For example, lighting a candle shouldn’t be reason for alarm, but if it persisted and became obsessive, it was likely a reliable sign that I was cycling up
Try to remove triggers. I learned to turn off the news when news events started to wear on me
If I feel consumed by a social mission or issue, I try to step away. Recognize that many are issues are out of my control. Discuss my preoccupation with my doctor and spouse
If I have been stewing over something all day, I try to get out of the house and/or talk to a friend. Go for a walk or hit the gym
Step 4 – Assign responsibilities
For me, recovery has been a team effort with doctors and family. Along with developing rules, we also assigned responsibilities for actions based on these rules.
As a witness to my previous episodes, my spouse has a great sense for early indicators that I am cycling up. He has my blessing to contact my doctor when he sees me showing these signs. I asked him to communicate with my doctor by text or email with a copy to me so that I am not excluded and there’s no miscommunication
We must trust each other. I know that my doctor will be objective and not accept my spouse’s word as the authority. He does his best to evaluate everyone. We all need to be open to the others’ perspectives and trust that our common goal is my recovery
Step 5 – Implement the plan
In the past, I had often resisted and resented my doctor and spouse taking control when I started to cycle up. Now, I maintain control and allow myself to be a partner in my treatment by putting in place a plan that provides for different scenarios.
I authorized my spouse to speak with my doctor and the protocol for communication mentioned above
I recognize that my spouse needs to take control when I’m no longer in a position to make lucid decisions for myself. I have prepared formal instructions for this scenario, but I should better formalize them in an Advance Psychiatric Directive
My doctor, Dr. Joseph Goldberg, who has expertise in bipolar disorder, recently offered a good driving analogy to understand the value of partners in care. Someone with mental illness should recognize that they can’t always observe the risks on their own of a brewing manic episode. Sometimes, we know that there are blind spots, like in driving, in our perception of these risks so we are careful to navigate away from them. At other times we mistakenly ignore a blind spot and get into an accident. Our ability to realize blind spots exist when we don’t see them and ask for help to point them out helps to keep us healthy and safe. We need partners in care to point out the blind spots we don’t see.
Katherine Ponte, BA, JD, MBA, NYCPS-P, CPRP, is a Mental Health Advocate and Entrepreneur and lawyer. She is the founder of ForLikeMinds, the first online peer-based support community dedicated to people living with or supporting someone with mental illness. You may follow ForLikeMinds on Facebook. She is on the NAMI New York City Board of Directors. She has also been living with severe Bipolar I Disorder for over 15 years and is currently living in recovery.
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