Why mood is important to your quality of life
Mood is fundamental to quality of life for people with or without bipolar disorder, but the extreme mood states of depression and hypomania or mania are characteristic problems in bipolar disorder. Here we will tell you about the most important strategies for improving your mood generally, and for minimising your risk of sliding into a depressive, hypomanic or manic mood state.
Mood in bipolar disorder
It’s useful to describe ‘mood’ as a diffuse feeling state that lasts for hours or days. Moods are different from emotions — emotions are more immediate experiences, they normally have a particular target (“I feel excited about…”) and are typically brief (seconds or minutes) and more intense than moods1. When you have bipolar disorder, your moods can get the better of you. At their worst, extreme mood states could lead to hospitalisation, problems with employers and loved ones, and sometimes even run-ins with the police. As well, during recovery, they can affect your quality of life as you try to put your life back together again. The extreme mood states that cause problems in bipolar disorder are: depression, mania and hypomania. Common symptoms of each include:
- Depression: Low mood and motivation, feeling flat or sad. It’s also associated with changes in sleep, energy and concentration and often by feelings of worthlessness or guilt. It can be accompanied by unrealistic beliefs and perceptions in severe cases. A depressive mood state lasts at least two weeks and is so severe that it significantly disrupts your ability to function.
- Mania: Elevated or irritable mood and hyperactivity. It’s associated with increased self-esteem, racing thoughts, distractibility, decreased need for sleep and engaging in risky activities such as those involving money or sex. Unrealistic beliefs and perceptions can arise in extreme cases. A manic mood state lasts at least one week and is so severe that it affects normal functioning.
- Hypomania: Some people call this “mania-lite”. It includes all of the symptoms of mania, but doesn’t cause significant lifestyle problems.
Staying well with bipolar disorder involves optimising your mood all the time through lifestyle changes and keeping an eye out for triggers (we’ll discuss these later on) and early signs that you might be sliding into a mood episode. Your aim should be to stay in the ‘happy medium’ – able to feel the normal highs and lows of life, but without too much stress and anxiety and without sliding into one of those extreme mood states.
Even when not experiencing full-blown episodes of depression and hypomania or mania, people with bipolar disorder often have problems with low mood and anxiety 2,3. People with bipolar disorder can benefit from the same strategies and behaviours that help everyone stay happy and calm. Many of these are discussed elsewhere in the Wellness Centre, where we discuss other aspects of quality of life that strongly impact mood (e.g., the domains of Sleep, Physical, Relationships, Independence, etc.). Here, we’ll focus on activities that can lift a lowered mood, decrease anxiety and stress, and some tips for what to do if you feel like you may be moving into a mood episode.
How you can take action
People who manage their bipolar disorder well tell us that it’s important to have a technique for relaxing, and to use it every day4. There is a big difference between an activity that tends to be relaxing (e.g., perhaps you find cooking or watching TV relaxing), and an activity that you deliberately do solely for the purpose of relaxation: an ‘active relaxation’ strategy. Such ‘active relaxation’ strategies might include meditation, yoga or mindfulness-based practices. If you don’t have an active relaxation strategy, it’s worthwhile to look into one. Other stress management strategies include becoming aware of triggers for distress, developing the interpersonal skills of assertion (e.g., speaking up for yourself and others, disagreeing respectfully or saying ‘no’ without feeling guilty5), and becoming better at problem solving life’s difficulties. If you’re not used to these ways of dealing with stress and anxiety, it can help to be shown them in a course or with a counselor or therapist.
One of the most common problems faced by people with bipolar disorder is continuing mild depression and lack of motivation6. The skills of stress management, assertion and problem solving that are useful for anxiety (see above) are also powerful tools for dealing with a low mood. Depression involves low motivation, low energy and a tendency to pick on yourself. Each of these problems can be tackled by pre-planning your week’s activities: hour-by-hour, for each waking hour of the day. The sorts of activities you record might appear simple (e.g., get out of bed and have a shower), but considering that you are feeling unmotivated, successfully completing such activities can be quite an achievement. Such ‘activity scheduling’7 does a number of helpful things. It takes the pressure off of you having to decide what to do in the moment (the decision is already made), gives the day structure and momentum and enables you to build in activities that you may find pleasurable.
Of course, a challenge for people with bipolar disorder is that they can get too energized and excited about activities. It’s useful to talk to someone about your scheduled activities to make sure you strike the right balance.
There are three steps to minimising downwards and upwards mood swings. First, monitor your mood and wellbeing daily for changes, second, keep an eye out for triggers, and third, respond early if you are sliding into an episode.
It’s useful to monitor your mood and wellbeing. There are many ways to do this, and many free mood-monitoring apps or websites that you can use to track your mood (see Mood Resources). You might even find that it’s useful to make up your own monitoring scale: it could be a scale from ‘depressed’ to ‘manic’, from ‘dark’ to ‘light’, from ‘flat’ to ‘excited’ – whatever terms resonate with you.
People often worry about the difference between normal changes in mood and a mood change that might signal a problem. A good way to know the difference is to see if you can change your mood. If you’re feeling a bit flat, see if you feel a bit better by doing something you would usually enjoy (e.g., treat yourself to your favourite TV show). If your mood lifts, it’s all good. If your mood stays flat or low, then you might need to get some more help. Similarly, if you’re feeling particularly happy and excited, see if you can moderate the mood by taking a few minutes away from stimulation (e.g., sit down and read quietly). If you remain high and can’t concentrate, your mood might need some attention.
Become an expert on your personal triggers for changes in mood. There is growing evidence that life stress can cause severe mood changes in bipolar disorder8. You can work out what these are by looking over your life and noting the sorts of events (e.g., interpersonal, physical, environmental, etc.) that tend to unsettle you. There are also certain triggers that seem to be important for many people with bipolar disorder9. People with bipolar disorder are often helped when they’re cautious around their mood if any of the following are going on:
- Changes of season: A proportion of people with bipolar disorder are at increased risk of depression in the darker months and of hypomania or mania in the spring or summer.
Changes in sleep: Decreased sleep can increase the risk for hypomania or mania, and increased need for sleep is sometimes a sign of depression.
- Changes at work: Both negative and positive events at work can be triggers for unsettling your mood.
Relationship stress: Conflict and fights in a relationship are stressful for everyone, and can increase risk for mood episodes.
- Pregnancy and childbirth: Everything changes with a baby, and biological, behavioural and social changes with pregnancy and childbirth are a major risk factor for triggering mood episodes. Most research has looked at mothers, but fathers may go through many of these changes too10,11.
- Grief and loss: Loss comes in many forms and affects everyone. Grief, divorce, losing a job, or permanent loss of health or security, can challenge anyone’s coping resources. People with bipolar disorder need to be particularly careful at these times – there’s a difference between the normal process of adjusting to a loss and the development of a new episode of depression, hypomania or mania.
- Drugs and alcohol: Stimulating drugs like cocaine, speed and other party drugs are of course triggers for the disturbed high mood states and the dangerous impulsivity of hypomania or mania. Alcohol use is linked to depression.
Research has shown that there are some signs that are commonly reported in the early stages of extreme mood shifts12,13. Early signs that someone might be becoming depressed include low energy, feeling tired, difficulty concentrating, intrusive negative thoughts (those unwanted thoughts that keep coming back), wanting to be alone, feeling irritable, sleeping too much or too little, feeling sad or wanting to cry, feeling flat, feeling anxious and feeling guilty.
Early signs that someone might be becoming hypomanic or manic include feeling emotionally high, ideas flowing too fast, senses seeming sharper, colours seeming brighter, feeling especially creative, feeling irritable, increased interest in sex, difficulties falling asleep, feeling self-important and making lots of plans.
An important idea is that how we think and act can have a big impact on our moods.
There are some issues that you can usefully focus on by changing how you respond to a change in mood. All the strategies involve decreasing stimulation of all kinds, slowing down behaviours and plans, decreasing the hunt for rewards, and decreasing emotionality and how you express your emotions. It’s important to not over-interpret your change in mood, though. It can be tempting to think that increased energy and speed of thought says something about you personally, but remember, your mood isn’t who you are, it’s just your mood at this point in time14
. People who can recognise the early signs of mood episodes, and who respond in a timely and helpful or positive way, have a better course of bipolar disorder.
Questioning your thinking before you act can help with manic moods. People who are a bit manic can behave in ways that are unusual, dramatic, or flamboyant15,16,17. For example, you may feel so excited, that you choose clothing that is inappropriate to the situation, and overlook the potential damage to your reputation. It’s useful to question your thinking at these times, and you could ask questions like:
- Is this what I would normally wear in this situation?
How will others react to what I am wearing?
- What harm is there in stepping back and fitting in with others today?
A manic mood can lead people to seek out dangerous or inappropriate sexual behaviour (unprotected sex, seeking out sex workers, sexually-harassing behaviour)18,19. Hypersexuality may be made worse by alcohol or drugs. At such times, you might start to think things like: “She is definitely attracted to me”, “Everyone likes me”, “I’m incredibly sexy.” One potential action strategy in such situations is to give yourself 48 hours before taking any action. To counter this type of thinking in the moment, you could ask yourself questions such as:
- Is it possible she was just being friendly?
- What are the consequences to me if I overestimate how much he likes me?
- Why not wait a while to see what she really feels?
- Have I ever felt this way before, even when I wasn't manic?
Could I be misreading his behaviour?
When someone with bipolar disorder is high, they can feel under pressure to make quick decisions20. This is called impulsivity, and it might appear in different areas of your life (e.g., finances, sex life, relationships) and can include aggressive acts. At highly impulsive times you might think: “If it feels good now, do it”, “I’ve got to act now”, “I’m sick of being controlled”, “I should never pass up an opportunity”. At moments like these you may want to take the action strategy of turning inwards for just 30 minutes before acting, to list the pros and cons of the action your are considering. You could also make a list of negative outcomes of past impulsive actions. It also helps to question thoughts like these with questions like:
Why not take a bit more time to think about my course of action?
- Have there ever been negative consequences of my impulsivity before?
How you think and act can impact on whether a mild depressed mood turns into a severe episode of depression21. There are some common issues you can focus on by changing your response to a change in mood. The strategies centre on putting structure and activity in your day, and continuing to stay engaged with people and other parts of your life even if you don’t particularly feel like it (we considered such strategies above). It’s also important to keep an eye on how you’re thinking. When people are a bit down, they tend to think in some of the following unproductive ways.
All or nothing thinking, or perfectionism, refers to thinking about things at their extremes. Things are either ‘good’/perfect or ‘bad’/inadequate – there are no grey areas with this type of thinking. For example, “If I don’t get that job I have applied for it means I am hopeless and no one will ever employ me”. “If I get frustrated with the children, it means I am a bad parent.” If you have these thoughts, know that there is evidence that counters them – and look for it.
“Most people have to apply for a number of jobs before they get one.”
- “All parents get frustrated sometimes; this doesn’t make me a bad parent and I do lots of great things with my kids.”
Catastrophizing or fortune-telling involves jumping to a negative conclusion. These thoughts can have their own momentum, and can “snowball” – that is, imagined negative impacts can grow quickly until they feel out of control. Not surprisingly, these types of thoughts are linked to feelings of anxiety and depression22,23,24. For example, “My partner was short with me this morning, so he must be upset with me… maybe he doesn’t even love me anymore.” To counter snowballing negative thoughts like this, ask yourself about other things that might have influenced this situation.
- “How do I really know this?”
“My partner has an important meeting today that she is worried about, that is probably why she seems distracted.”
Mind reading is the belief that you know what other people are thinking. This type of thinking can be associated with feelings of anxiety, particularly in social situations. For example, “They must think I am really stupid for saying that.” If thoughts like this arise, ask yourself:
“Where is the evidence for thinking this?”
- “How can I possibly know what they are thinking?”
“What else could they be thinking?”
- “I have no idea what they were thinking, maybe they were thinking ‘when’s lunch?’”
Overgeneralizing is a type of thinking when you believe that something bad will always occur, based on a previous unpleasant experience. These thoughts state that things will be like this ‘always’. For example, “I didn’t do well in high school 15 years ago, so I will not do well in this training course now”. Try to ground your thoughts a little to the specifics, to this point in time, right now. Question these thoughts by asking yourself:
Finally, have a plan for if the mood episode gets serious.
- ”How can I know this will be so?”
- “High school was 10 years ago, but this is a course I have chosen and am interested in – that is a big difference.”
It’s important to be prepared for the possibility that your mood gets the better of you. There is research showing that having a well thought out written-down plan for mood emergencies is useful25,26
. Plan what you’ll do, what you’ll say, whom you will communicate with, what you will ask family and friends to do for you. For example, you may ask a friend to take away your credit card if you’re feeling manic, or ask your sister to drop in if you stop returning her calls. It’s useful to check with the people in your plan to make sure they’re willing to play these roles. You may want to give friends or family permission to let you know when you’re becoming unwell (and perhaps tell them how you would like to hear this information).