Routine Maintenance: Sticking to a Schedule Helps Maintain Balance for Bipolar
Sticking to a regular daily schedule helps keep your body’s internal clock ticking steadily and contributes to better sleep and more balanced moods.
By Sasha Kildare
Toting my workout bag, I pass a co-worker in the hallway who remarks, “You are so good about exercising.”
I muzzle myself to keep from voicing my instant reaction: “Fear of psychosis is a pretty good motivator!” Instead, I smile and say, “Too much sitting.”
I’m faithful to my exercise routine—30 minutes of intense activity, six days a week—because it helps me sleep through the night and combats the tentacles of depression. Two other simple routines have kept me from flirting with mania for years: Taking my medication by 10 p.m. and getting to bed by 10:30.
It turns out there’s a lot of science to back up the importance of regular daily habits when you live with bipolar disorder. In fact, some researchers have suggested that bipolar links to an “underlying circadian pathology.”
A bit of background: Circadian rhythms are biological cycles that occur roughly every 24 hours. They are governed by a countless array of individual “clock genes” throughout the body as well as a “master clock” in the brain called the suprachiasmatic nucleus (SCN).
Greg Murray, PhD, a leading researcher into bipolar and circadian rhythms, describes it this way: “The circadian system is like the drummer in a band. Everyone in the front line can play their solos and melodies, but if the drummer is unreliable, the people in the front line can’t engage with the audience and be present.”
Murray, who is a professor at Swinburne University in Melbourne, Australia, uses phrases like “arrhythmic” and “prone to dysregulation” to describe the circadian system in people with bipolar.
In another colorful metaphor, he urges the need for scaffolding—in the form of daily routines—to shore up the shaky mechanism and achieve a good quality of life.
“The regularity of activity, separate of the types of activity … keeps the body clock in tune,” he says.
The power of regularity was demonstrated in a recent British study of flight crews who regularly cross multiple time zones. Keeping to a regular schedule of meals on days off was shown to reduce jet lag irrespective of sleep habits. The researchers noted that eating meals at appropriate times in the light-dark cycle helps synchronize the circadian system.
“The regularity of activity, separate of the types of activity … keeps the body clock in tune.”
Brad of Los Angeles has structured his life around regular mealtimes and a strict schedule for his writing activities.
On Sundays, he writes most of the posts for his blog, Insights From a Bipolar Bear. On weekdays he walks five miles to the public library—getting in exercise and exposure to natural light, which are both important in regulating mood—and works on his novel from noon to 5 p.m. He also sets aside time to keep up with other writers and current events.
“During the week, I try to read two hours’ worth of blogs—one hour before breakfast and one hour after dinner,” he says.
Through his participation in Weight Watchers, Brad learned to plan meals in advance. He preps breakfast and lunch the night before, which makes it easier to eat at the same time every day.
The bottom line: Regular habits help regulate the running of your biological clock.
“Everything we do sends messages to the brain. Every activity affects body temperature, cortisol levels, and more,” explains David J. Kupfer, MD, a distinguished professor emeritus of psychiatry from the University of Pittsburgh Medical Center.
“That first meal of the day and the last meal of the day are very important. When you exercise, in terms of regularity, is vital. You should take naps at the same time.”
In some ways, Kupfer says, “doing everything at the same time every day … can be just as powerful as taking medication.”
But what if sticking to a routine doesn’t come naturally? That’s when sensible goal-setting comes into play.
Articulate the change you’re aiming for—eating a healthy dinner every evening at 6 p.m., for example—then break it down into manageable steps that will move you in that direction.
Setting goals that are too hard to meet is setting yourself up for failure, warns Louisa Sylvia, PhD, an assistant professor of psychology at Massachusetts General Hospital and author of The Wellness Workbook for Bipolar Disorder.
“A big chunk of the work we do is understanding what are realistic goals to achieve and how to reward yourself appropriately,” says Sylvia, adding: “Learning how to reward yourself takes practice like any other new skill.”
Sylvia recommends basing your desired changes on what you are already doing and building up routines slowly, extending bit by bit as each new behavior becomes more established.
“I always want people to realize that they are probably doing more activity than they realize, such as changing their clothing or walking upstairs,” she says.
Take Brad as a case in point. His structured life of today looks far different from the period following his diagnosis more than a decade ago.
“I kept my list really short. Wake up. Go to post box to get outside. Take a shower. Dress. … Doing those four things would be a full day for me at the time.”
He adds, “I am lucky in that I married someone that is a huge cheerleader for the whole thing. He helped me establish a good schedule, especially in the beginning, and would double-check to make sure I was doing those things.”
It’s essential to not get discouraged by slow progress or setbacks.
As Kupfer points out, “Any chronic condition requires you to buy in and take ownership. You have to be able to control your own changes in establishing routines and learn what goes well and what doesn’t go well.”
Establishing consistent daily routines is especially challenging when your work schedule doesn’t cooperate.
“People with bipolar disorder tend to be creative and not to like routine, so they can be attracted to jobs with tight deadlines like musician, cook, or journalism—jobs that don’t have routines built in,” Murray says.
When Murray counsels musicians who are having trouble with their moods, he asks them, “What is it about being a musician that you value, and how do you protect that while you make some changes?”
Brainstorm ways to break down the day, such as scheduling music students and personal practice in a regular block every morning and setting a time in the afternoon to answer emails and arrange gigs. Additional planning can address how to handle disruptions like late nights and time on the road.
Mauricio, a tennis teacher and coach in Southern California, has a hectic schedule between his various tennis jobs and attending college part-time. His workout and end-of-day routines keep him on track, along with a daily meditation practice.
Mood shifts present another obstacle to sticking with your routines. If motivation lags during depression, Murray recommends a two-prong approach: cognitive and behavioral.
Cognitive strategies involve training yourself to notice critical self-talk and other negative thoughts and countermand those defeatist notions. On the behavioral side, Murray recommends sitting down with someone—a friend, therapist, or partner—to plan in a diary what you will do every hour over the next week.
“The next day, you’re by yourself, you look at your schedule, and the decision has been made. There is nothing to decide. When we’re depressed, one of the things that keeps us stuck is indecisiveness,” Murray says.
The challenge with mania or hypomania is taking on too many activities. A good question to ask: “How many new plans have you got at the moment?”
Murray recommends giving permission to someone you trust to let you know when your behavior hints at elevated mood.
Mauricio credits the awareness that comes from regular meditation with letting him know when it’s time to cut back on commitments so that he doesn’t head toward mania or depression.
“All it takes is 10 to 15 minutes to be able to sit still in a place where there is not a lot of stimulus, mind my breath, settle into where I am sitting, and let my mind go away from the rush of thoughts and into breathing,” he says.
When it comes to regular routines, getting your “sleep-wake cycle” in order plays a huge role in wellness.
Many of the standard recommendations from sleep specialists keep your circadian rhythms in synch, including getting up at the same time even on weekends and going outdoors early to absorb morning light.
Evening rituals for winding down train the brain to prepare for sleep. Popular methods include having a cup of non-caffeinated tea (chamomile is documented to have a sedative effect), taking a hot bath (the rise and subsequent drop in your body’s baseline temperature appears to promote sleep), and listening to calming music.
Mauricio has a number of strategies to help him relax. He might stretch for 10 minutes using a foam roller or do breathing exercises to release physical tension. He might make a to-do list for the next day on a whiteboard or piece of paper so he won’t continue to fret.
“If I lie down with a tense body, if something is bothering me, I will be restless,” he explains.
Mauricio started learning about healthy behaviors and stress reduction while participating in a research program at University of California-Los Angeles. Weekly visits with a psychologist help him to maintain and build on what he learned.
“That first meal of the day and the last meal of the day are very important. When you exercise, in terms of regularity, is vital.”
Recruiting support for lifestyle changes can only help. There’s actually a specific therapeutic approach called interpersonal and social rhythm therapy that was developed to help people with bipolar cope with circadian disruption. However, the tenets of rhythm therapy have spread into many other settings.
“In group treatment, we talk a lot about the importance of structure and routine. It’s foundational,” Sara Lapsley, MA, says of her counseling work at a psychiatric hospital in Vancouver.
Before her own bipolar diagnosis in 2001, routine was not in Lapsley’s vocabulary. A former punk rocker and veteran of the Vancouver music scene, she was no stranger to chaos. These days, Lapsley finds that rehearsing twice a week with her band, the PRNs, gives “rhythm to the week.”
She shares her personal wellness journey with the people she counsels to emphasize how regular habits help control mood shifts.
“Most people have had devastating episodes… If stability can offer some protection against reoccurrence of an episode, it’s a small price. It’s more fun to live an unfettered life, but ultimately structure and routine pay off.”
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In the rhythm
Circadian rhythms are physiological changes that follow a roughly 24-hour cycle. (“Circadian” means “around a day” in Latin.) Research has shown that some of those daily oscillations, including basal body temperature and certain hormone levels, look different in people with bipolar than in the general population.
That’s one clue that bipolar disorder may link to irregularities in the circadian system.
Such a link would explain “high day-to-day variability in activity and sleep timing” in people with bipolar, reports Isabella Soreca, MD, of the University of Pittsburgh Medical Center, as well as “persistent disturbances of sleep or wake cycles.”
In other words, having bipolar goes along with a tendency toward day-to-day shifts in when you get hungry, when you feel most alert, what time you go to bed, and how long you stay asleep.
Another clue: The body’s “master clock,” the suprachiasmatic nucleus (SCN), has a direct connection to the eye’s retina and responds to light signals. People with bipolar appear especially vulnerable to such cues. For example, seasonal changes in length of day and crossing time zones count among common triggers for mood shifts.
Synching your sleep
Fluctuating levels of melatonin, a hormone made by the pineal gland, direct the body’s sleep-wake cycle—when we feel ready for bed or ready to start the day. The system is governed by light signals. Melatonin levels should rise as sunset approaches, preparing us for rest. Morning light shuts down production so that we’ll feel more alert.
Exposure to bright light early in the day contributes to better sleep by synching the melatonin “clock.” Keeping the house dim as you approach bedtime—and avoiding use of electronic devices with “blue light” screens—allows the melatonin cycle to follow its natural pattern.
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Printed as “Routine maintenance”, Winter 2017