Seasonal patterns of mania can give that phrase “spring fever” a whole new meaning when living with bipolar disorder
Margie P. of New Jersey recently sang on stage for the first time in a decade, reclaiming a piece of herself. Her last hospitalization stemmed from a springtime manic episode, so she totally relates to the lyrics of the jazz standard “Spring Can Really Hang You Up the Most”:
Spring came along, a season of song,
Full of sweet promise
But something went wrong.
“My grandiosity led me to apply for jobs for which I had none of the qualifications, start businesses for which I had no funding, hear voices that were not there, and struggle with severe agitation and restlessness,” the New Jersey woman recalls.
As necessary as her inpatient treatment was, though, there was something especially galling about the timing.
“There is nothing worse than being behind a locked door during the season in which the majority of the population are out enjoying activities such as bike rides, walks, and softball,” she says.
Not everyone with bipolar is vulnerable to mood episodes that coincide with the seasons (known as seasonality). For those who are, the typical pattern is depression that recurs in winter and hypomania or mania in springtime or summer.
It can be difficult for individuals to realize what’s going on, Aiken says.
“Most patients … will identify the depression in the winter. But it will take a lot of pulling for them to identify the mixed episodes in the spring.”
It’s even harder when hypomania simply feels like a welcome rebound from winter’s depression. Aiken identifies three common warning signs: sleep irregularity, rapid speech, and physical hyperactivity.
Check, check and check for Steve F., who traded the stress of life in Los Angeles for the calmer pace of a small town in Pennsylvania.
“When I was in L.A. it didn’t seem like I could get much sleep. In the big city it was like mania every day. I had a case of the ‘gottas.’ Gotta go meet someone new. Gotta get smarter. Gotta, gotta, gotta,” he says.
“Here I get cooped up. You get locked in and snowed in for months. When spring comes, it’s almost like somebody put me in a slingshot and thrust me out the door.”
A veteran stagehand, Steve goes through a work lull during the heart of winter. Springtime brings more assignments, which can challenge his sleep schedule, which in turn can trigger mania.
When spring comes, it’s almost like somebody put me in a slingshot and thrust me out the door.
“I’m always looking for something new that I’ve never done before. That’s what makes me feel complete, alive, like I have something to look forward to…. Spring is when that kicks in and I just go into overdrive.”
According to Anthony Levitt, MD, a psyLucianieatrist and scientist at Sunnybrook Health Sciences Centre in Toronto, about 50 percent of patients with bipolar have seasonal mood shifts. However, he adds, that figure includes those with mild seasonal symptoms and others with only winter symptoms.
As far as what sets off spring mania or hypomania, he says, “It’s not just one thing. It’s a combination of things.”
That could include an individual’s psychological reaction to spring’s arrival; how someone responds to weather factors such as wind, barometric pressure, and temperature; and an underlying biological sensitivity to day length.
Longer days often mean more evening activities and more opportunity to socialize, which can translate into more reasons not to get to bed on time. However, Aiken says, “A lot of research shows that it’s not the quantity of light. It’s the rapid change in light.”
Quick refresher course: Starting with the winter solstice in December—the shortest day of the year—the amount of daylight starts to increase until the summer solstice in June, which is the longest day of the year. The further from the equator, the greater the overall change in length of day.
Aiken points out that the fastest rate of change in daylight occurs around the equinox, the point when there are equal hours of day and night. (This happens twice, around March 20 and September 20.)
The reason that matters has to do with our circadian rhythms. That’s a roughly 24-hour cycle of activities pegged to an internal clock. The circadian rhythm influences things like when we would naturally wake up and go to sleep, when we’re hungry, when we feel most alert. It can be influenced in turn by a variety of external factors.
Science suggests that people with bipolar are particularly susceptible to disruptions in circadian rhythm, and there’s a strong link between those disruptions and onset of symptoms.
“Most definitely people with bipolar have trouble with change with regard to circadian rhythms—jet lag, changing seasons, change in routine of any kind,” Levitt says.
In fact, there’s a psychosocial intervention called interpersonal social rhythm therapy that’s based on evidence that people with bipolar benefit from greater structure in their lives. The therapy also addresses issues that can throw someone’s routine out of whack, such as work stress and relationship problems.
Maintaining a consistent treatment plan is the first line of defense against seasonality. Yet there are also important self-help strategies, such as awareness and lifestyle accommodations, that play a part in smoothing out seasonal moods.
1 Pattern recognitionUsing a mood tracker over a long period of time makes it easier to pick out seasonal patterns, notes Levitt. There are a variety of tools available in paper form and online, including smartphone options that turn noting your daily status into a quick process.
Levitt stresses the importance of using separate scales for depression and mania.
Recording your moods day by day, or even week by week, can be especially useful in catching hypomania. Retrospective reporting—that is, thinking back to try to remember whether and when you had a mood episode—is notoriously unreliable. Something major like a hospitalization would stay on your radar; less dramatic symptoms, not so much.
A lot of research shows that it’s not the quantity of light, it’s the rapid change in light.
Candida Abrahamson, PhD, who has a counseling and personal coaching practice outside Chicago, emphasizes the value of outside input from family and friends who know you well. Such observers are often quite adept at recognizing early signs of a mood shift, she notes.
Steve maintained a daily mood journal for two years, which clued him in to springtime symptoms.
His method was to write down what he was thinking about, then draw smiley faces, frowny faces or some other icon to indicate how he was feeling. He did that when he got up in the morning, then several more times during the day.
He says greater self-awareness helps him keep mania at bay when he goes into overdrive: “I have learned how to channel that energy into something positive.”
As a short cut, Abrahamson recommends reviewing events and encounters that occurred before your last manic episode or episodes in order to identify circumstances that made things worse. The next step is evaluating whether any of those circumstances could be modified.
“Seasonality can’t change,” she notes, but you’ll probably discover behaviors you can adapt—skipping that midnight movie, say, or limiting time with a highly critical friend.
“We do have more control over our lives than we think,” she says.
2 Short-term savvyKeeping a mood journal not only helped Steve decipher seasonal patterns, but also paid quick dividends in day-to-day management of symptomatic behavior.
“After about two weeks, I began to recognize what type of people and what type of situations would set me off and trigger my emotions,” he recalls.
When something made him angry, he would slam doors and act out. Or “when somebody said something I didn’t like, my mouth just went flying.”
Now he’s better at catching himself and not letting anger get the best of him. Instead, he trained himself to remain quiet and not react. He consciously practiced this new behavior for an entire year until it became almost automatic.
Journaling also made Steve aware of the connection between having nightmares and waking up tired and anxious. That enabled him to use morning routines to defuse tension, such as doing a little bit of yoga.
3 Regulate your rhythmsBecause people with bipolar tend to have “fragile circadian rhythms,” as Aiken puts it, it’s important to look at how aspects of your daily routine might help or harm you.
“You have to learn how to negotiate your schedule,” Aiken says.
Physical activity, sleep patterns, and eating patterns all affect circadian rhythm. Monitoring these activities closely during the change of seasons can help moderate the impact of that change.
For example, the timing and intensity of exercise can influence how well you sleep. Generally, evening exercise is not recommended for anyone who struggles with insomnia.
(Aiken notes that exercising too much can be a sign of mania, but he dismisses concerns that intense exercise causes mania. In fact, he says, “Exercise strengthens the brain in ways that prevent mania.”)
Research has established that out of the several hundred things people do regularly every day, four habits have the biggest impact:
• Time you get out of bed in the morning
• First significant contact with people
• Time that you start your work or chores
• Time that you eat dinner
According to Levitt, avoiding dramatic fluctuations in biologic processes from one season to the next is key. It is important to be consistent not only in when you eat, for example, but also in how you eat. You may feel less inclined to prepare good meals at different times of the year, but it’s important to push yourself to stay on track.
Regulating sleep is critical too. “You really can’t have an episode of mania with normal sleep,” Levitt says.
4 Lighten upAiken explains that those with fragile circadian rhythms need a strong sunlight signal to set their internal clocks, which tend to run a little slow. He says light therapy can help buffer the rapid shift in daylight by maintaining the same overall exposure during transition periods.
Because seasonality in bipolar reflects a biological rhythm that is “hungry for regulation,” Aiken recommends as much natural light exposure as possible during the winter to counteract depression. In addition, using a light box or similar device for 15 to 30 minutes in the morning can be a valuable treatment for winter depression.
As spring approaches, the light therapy would be tapered off. Overexposure to light can throw off rhythms, too.
“In someone with bipolar, light therapy has to be done with the same kind of consideration as if you were using antidepressants,” says Levitt.
My support systems are crucial. I know I can go to any of them at any time.
About four years ago, Kate R. from southern California realized that her worst manias occur in the spring, mostly in May and June. Such episodes find her pacing, feeling uncomfortable everywhere, feeling as if her heart is going to jump out of her chest, and popping up to a sitting position once an hour as she tries to sleep.
Kate’s psychiatrist suspects that sensitivity to light may factor into her vulnerability to spring mania. When Kate has panic attacks in the winter, however, she follows the doctor’s advice to “go sit in the sunlight. I have incorporated it into my routine now.”
5 Plan wellKate also uses mindfulness practice to stay in tune with subtle body changes and keep alert to how she’s interacting with others. She also relies on her support team to help stop mania from taking over in the spring.
“My support systems are crucial. I know I can go to any of them at any time,” she says.
Margie, meanwhile, has managed to stay out of the hospital for the past six springs through a combination of exercise, support groups, monitoring her mood and medicines, and cutting back “if I am going in too many different directions.”
Pet sitting is also a significant stay-well strategy. Not only does walking dogs force her to stay physically active, but she also gets to play with and nurture the animals.
Someday, when she could handle the stress, she would love to have a pet-sitting nonprofit staffed by people with mental illness.
For now, though, “I live in the day. I pray that if I continue to do the next right thing … I will be able to remain in the community and not have to check back into the hospital.”
And for now, with her wellness plan in place, she can hum along to the Beatles:
Here comes the sun
Here comes the sun, and I say
It’s all right.
Printed as “Spring Fever,” Spring 2014