“One of the most confusing—but ultimately liberating—steps for peo-

ple with bipolar disorder is getting that initial diagnosis. Often frighten-
ing, upsetting, and filled with shame, you don’t know what to expect or
what to do. Bipolar Disorder: A Guide for the Newly Diagnosed by
Caponigro, Lee, Johnson, and Kring fills this gap. This highly readable
and accessible guide provides you with basic information on how to
recognize the important symptoms of bipolar disorder; the essential role
of medication and which psychological treatments can be helpful; and
how to cope with family, friends, work, and on-going self-care. I know
that this book will be invaluable for those coping and living with bipo-
lar disorder and will give much needed hope and guidance. I strongly
recommend this guide for those new to their diagnosis. In many ways,
coming to terms with the illness and acquiring effective coping skills
are part of that first step toward getting better, and that first step may
prove to be the most important one.
—Robert L. Leahy, PhD, author of The Worry Cure and
Beat the Blues Before They Beat You

“This is a very readable and comprehensive book for someone adjusting

to a diagnosis of bipolar disorder. The discussions of the social aspects
of the process—for example, who to tell and what to say, or meeting
with a therapist and building a treatment team—are particularly help-
ful. I highly recommend this book as a first step to fitting bipolar disor-
der into a full and satisfying life.”
—Greg Murray, professor and head of psychology at
the Swinburne University of Technology, Australia
“Bipolar disorder can be a debilitating illness that affects every
aspect of life. Forewarned is forearmed, and this text provides
invaluable information for people with bipolar disorder and the
people who love them about what to expect from the illness and
how to deal with it. The authors are among the most distin-
guished experts in the field. I strongly recommend this marvel-
ous and totally accessible text.”
—Steven Hollon, PhD, professor of psychology
at Vanderbilt University

“This is a very well written, accessible guide for someone recently

diagnosed with bipolar disorder, or their friends and family. The
key message is one of hope. People with bipolar disorder can find
ways to understand and manage their bipolar experiences in
ways that allow them to lead full and satisfying lives. This book
outlines the key steps to learning how to do this and covers both
medication and psychosocial approaches. The book includes
case examples to bring the key messages to life, and signposts
the reader to many other useful resources for more detailed
information. I think this book would be useful for anyone look-
ing for more information on how to best manage bipolar
disorder.”
—Fiona Lobban, PhD, DClinPsy, senior lecturer
in clinical psychology at the Spectrum Centre for
Mental Health Research at Lancaster University, UK
“Too often, the field struggles with what appear to be competing
demands for a scientific basis versus clinical acumen or presence
in the moment with each client. This book brings together evi-
dence, experience, and empathy in an all-too-rare amalgam. I
do not have a better word for it than ‘wisdom.’ Combining
proven interventions and recent developments, this book fills a
distinct and important role. I recommend it most highly.”
—Eric Youngstrom, PhD, professor of psychology and
psychiatry and acting director at the Center for
Excellence in Research and Treatment of Bipolar
Disorder at the University of North Carolina
at Chapel Hill.
 Guides for the
Newly Diagnosed
Series
New Harbinger’s Newly Diagnosed book series
was created to help people who have recently been
diagnosed with a mental health condition. We
understand that receiving a diagnosis can bring
up many questions. For example, whom should
you tell about your diagnosis? What treatments
are available? What are the best techniques for
managing your symptoms? And how do you start
building a support network?

Our goal is to offer user-friendly resources that

provide answers to these common questions, as
well as evidence-based strategies to help you better
cope with and manage your condition so you can
get back to living a more balanced life.

Visit www.newharbinger.com for

more books in this series.

c C
c C

Bipolar
Disorder
a guide for
the newly
diagnosed
Janelle M. Caponigro, MA, Erica H. Lee, MA,
Sheri L. Johnson, PhD, Ann M. Kring, PhD
New Harbinger Publications, Inc.
 Publisher’s Note
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted
practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any
consequences from application of the information in this book and make no warranty, express or implied, with
respect to the contents of the publication.
The authors, editors, and publisher have exerted every effort to ensure that any drug selection and dosage set
forth in this text are in accordance with current recommendations and practice at the time of publication.
However, in view of ongoing research, changes in government regulations, and the constant flow of information
relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug and
consult with their health care provider for any change in indications and dosage and for added warnings and
precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication may have Food and Drug Administration
(FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider
to ascertain the FDA status of each drug or device planned for use in their clinical practice.

Distributed in Canada by Raincoast Books

Copyright © 2012 by Janelle M. Caponigro, Erica H. Lee, Sheri L. Johnson, & Ann M. Kring,
New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
www.newharbinger.com

Cover design by Amy Shoup; Text design by Michele Waters-Kermes;

Acquired by Melissa Kirk; Edited by Jasmine Star

All Rights Reserved.

    
Library of Congress Cataloging-in-Publication Data
Bipolar disorder : a guide for the newly diagnosed / Janelle M. Caponigro ... [et al.].
p. cm. -- (The New Harbinger guides for the newly diagnosed series)
Summary: “Bipolar Disorder: A Guide for the Newly Diagnosed is a pocket guide to symptom
management, treatments, medications, and more for people who have been recently diagnosed with
bipolar disorder. Includes guidance for processing the diagnosis, sharing it with family and friends, and
finding experts who can help get symptoms under control”-- Provided by publisher.
Includes bibliographical references.
ISBN 978-1-60882-181-5 (pbk.) -- ISBN 978-1-60882-182-2 (pdf e-book) -- ISBN 978-1-60882-183-9
(epub)
1. Manic-depressive illness. 2. Manic-depressive illness--Diagnosis. 3. Manic-depressive illness--Treat-
ment. I. Caponigro, Janelle M.
RC516.B52228 2012
616.89’5--dc23
2012016989

Printed in the United States of America

14 13 12
10 9 8 7 6 5 4 3 2 1         First printing
We’d like to dedicate this book to
Donna Caponigro and Anthony Caponigro
Eric and Rosa Lee
Dan Rose
Angela Hawk
We also dedicate this book to all of the individuals who have
generously shared their experiences with bipolar with us over
the years. Thank you for inspiring us to write this book by
allowing us insight into your struggles and successes. It has been
a privilege to witness your journeys toward wellness.
 Contents

  Introduction 1
1  Understanding Bipolar Disorder 5
2  Receiving a Diagnosis and Finding Help 27
3 Medications 45
4  Psychosocial Treatments That Work 59
5 Learning to Notice Early Warning
Signs and Triggers 79
6 Strategies for Responding to
Warning Signs and Triggers 97
7  Telling Others about Your Illness 121
8  Staying Well and Staying Hopeful 139
  Resources 147

  References 153
 c
c

Introduction

Over the past decade, bipolar disorder, which is defined by symp-

toms of mania, has captured the public imagination and become
the focus of many movies. Rates of diagnosis have soared, and
Armani even markets a perfume named Mania. On the one
hand, we’ve been given images of highly accomplished individuals
who have this condition. Kay Redfield Jamison (1993) has
described evidence that authors Ernest Hemingway and Charles
Dickens, musician Robert Schumann, and artists Georgia
O’Keeffe, Jackson Pollock, and Mark Rothko all had this disor-
der. On the other hand, all too often people with bipolar disorder
struggle with sustaining jobs, relationships, and self-­esteem due to
mood episodes, and we are flooded with media images that por-
tray the dark side of an uncontrolled, untreated illness. In the
Bipolar Disorder: A Guide for the Newly Diagnosed

midst of these conflicting images, it can be hard to obtain care-

fully documented information about what the disorder really is
and how to manage it well. Our goal is to provide this.
We strongly believe that there are reasons for hope. Many
people with this condition learn to live full and satisfying lives,
and most say that they wouldn’t erase the disorder if they could
do so. But we want to be more than just an optimistic voice. This
book was written to help those with bipolar disorder begin to
control the illness, rebuild parts of their lives that have been dam-
aged, and sustain wellness. We see this book as a kind of tool kit:
a survival guide offering key resources and strategies on the path
to recovery.
We begin with the basics. For many people, mood episodes,
hospitalizations, and encounters with doctors can go by in a con-
fusing blur, so chapter 1 provides definitions of what doctors
mean when they use terms like “bipolar disorder” and “mania.”
Because misdiagnosis can and does occur in this era of busy
health care systems, we hope this helps you sort through some of
the confusing terms and lingo. We also provide a snapshot of the
biological roots of this condition.
With bipolar disorder, a key strategy is to find a good treat-
ment team. In chapter 2, we provide an overview of that process.
We discuss what types of providers to consider, note some sources
for referrals, and discuss what to expect during initial sessions.
For most people with bipolar disorder, medications will be the
mainstay of treatment. However, several different types of medi-
cations are used to treat bipolar disorder, and even within a given
category of medication, there are many different options. In chap-
ter 3, we explain the rationale guiding selection of medications

2
 Introduction

and also provide an overview of the most common side effects.

Our goal in this chapter is to help you understand that you have
many different options so that you can be an active partner with
your doctor in coming up with the best treatment plan.
Evidence based on studies of thousands of people with bipo-
lar disorder has clearly shown that adding psychotherapy to medi-
cations can help people recover from mood episodes more quickly,
maintain their periods of wellness, improve their social relation-
ships, restore their work lives, and reduce their odds of hospital-
ization. Several different types of psychotherapy have been proven
effective, and in chapter 4 we review the best of these.
Because bipolar disorder symptoms often come and go, most
people want to know why their symptoms emerge at a given time.
In chapter 5 we describe the most common triggers of depression
and mania. By helping you consider when and how episodes
might arise, we hope to enhance your sense that these episodes
can be predictable and therefore controllable. Most importantly,
being aware of triggers and early signs of relapse provides an
opportunity to cope with those early warning signs. Evidence
shows that this awareness helps people stay well, so we review a
host of possible strategies in chapter 6.
Without a doubt, adjusting to the diagnosis is a difficult pro-
cess, and one that is eased by the support of loved ones. Despite
that, having bipolar disorder raises lots of questions about rela-
tionships. Who should know about your diagnosis and symptoms?
How might you describe this condition to others? How do you
identify people who can understand this experience? In chapter 7
we discuss some of the core issues in making sure that you’re well

3
Bipolar Disorder: A Guide for the Newly Diagnosed

supported and understood as you gain better control over mood

episodes.
In chapter 8, we end the book by describing some of the
advantages that can come with this disorder, including evidence
that mania is linked to creativity, drive, and many other positive
traits.
It is our hope that this book provides a road map toward
health. We’ve watched many people as they learned to manage
their symptoms, achieved wellness, and built the lives they want
to live. We hope this book points the way toward that path.

4
 Chapter 1

c
c

Understanding
Bipolar Disorder

We believe that the road to health means learning everything you

can to help manage your symptoms of bipolar disorder. This book
is designed to increase your understanding of bipolar disorder and
teach you skills to prolong your periods of wellness. In this chap-
ter, we’ll share information about how doctors recognize and
diagnose bipolar disorder, the biology of the illness, and other
symptoms or disorders you may experience. We’ll also dispel a few
common myths about bipolar disorder. This chapter will provide
key information and establish a common language that will come
in handy throughout the rest of the book as we discuss treatment
options, illness management, and tools to help provide relief.
Bipolar Disorder: A Guide for the Newly Diagnosed

Bipolar disorder is a biological illness that affects your ability

to regulate your mood and leads to feelings of extreme happiness,
intense sadness, or heightened irritability. It is considered an ill-
ness because, like other medical disorders such as heart disease or
diabetes, it occurs after a biological change in your body, has well-­
described symptoms, and causes distress to people who have it.
The diagnosis of bipolar disorder is considered when a person
has had at least one episode of mania or hypomania (a less intense
form of mania). Many people with bipolar disorder also experi-
ence periods of depression, which is why the term “bipolar” is
used. So there are two broad categories of bipolar symptoms:
mania and depression.
The way people experience the symptoms of bipolar disorder
is highly individualized. Your experience will have both similari-
ties to and differences from the experience of others. However,
one aspect is consistent: At some point, these symptoms cause
distress or make it hard to function at work, school, or home, or
with family and friends. Many people with bipolar disorder need
professional help, such as seeing a psychiatrist or being temporar-
ily hospitalized, in order to manage their symptoms, remain in
good health, maintain their relationships, and enjoy a higher
quality of life.
Certain symptoms tend to occur together, and when they do,
mental health providers call this experience a mood episode.
Symptoms that occur while feeling high, euphoric, or irritable are
called manic or hypomanic episodes. Symptoms that occur when
feeling down, blue, or emotionally empty are called depressive epi-
sodes. In the next section, we’ll walk you through what experi-
ences and symptoms form the criteria for a mood episode.

6
 Understanding Bipolar Disorder

MANIC EPISODES
If you have a diagnosis of bipolar disorder, you’ve probably experi-
enced times when you felt extremely good, energetic, or high. It’s
natural to feel great at certain times in life, like after receiving a
promotion or hearing good news about a loved one. However,
people with bipolar disorder may feel overly positive or find that
their response to these types of events lasts for days longer than
what other people might experience. And for people with bipolar
disorder, sometimes these feelings of being on top of the world
seem to come out of the blue. Others find themselves experienc-
ing unusual and unexplained periods of irritability, argumenta-
tiveness, or impatience. For example, your conversations may
involve complaints or hostile comments, and you may even find
yourself arguing with strangers.
A manic episode is defined as a distinctly elevated or irritable
mood in combination with three or more additional symptoms of
mania (described below). These symptoms must last longer than
one week. When the mood state is irritable rather than elevated,
four or more additional symptoms of mania are required for the
diagnosis.

Mania Symptoms
Mania refers to the high or elevated periods of bipolar disor-
der. It is defined by a shift in mood that involves feeling extremely
good, excited, or euphoric, though a manic episode may also be
characterized by feeling irritable, argumentative, or impatient. In

7
Bipolar Disorder: A Guide for the Newly Diagnosed

addition to these changes in mood, mania includes experiencing

at least three or four of the symptoms described below:

INCREASED SELF-­CONFIDENCE
Everyone has qualities that are unique to them and impor-
tant, but during a manic episode you may believe in your abilities
with more confidence than usual. This may include thinking you
can do things that you may not be prepared or equipped to take
on or offering tips on a topic you may know nothing about.
Confidence is a good thing, but in mania your self-­esteem may be
too high, causing you to make inappropriate decisions. You may
feel as though nothing is impossible and every problem has a solu-
tion. Doctors may refer to this symptom as grandiose thinking.

DECREASED NEED FOR SLEEP

Most people need a certain amount of sleep to feel rested. In
a manic episode you may sleep much less than your normal
amount but still feel rested and energized in the morning. For
example, you may sleep three hours or stay up all night and still
be ready to start your day with as much energy as if you’d slept
nine hours.

TALKATIVENESS
Mania may cause you to talk faster and louder, or you might
start conversations with strangers. You may feel frustrated when
people ask you to repeat yourself. Sometimes a person is most
aware of these changes because of what other people say. For
example, others may tell you, “Slow down! I can’t follow what

8
 Understanding Bipolar Disorder

you’re saying.” or “Hey! Can I get a word in here?” This behavior

is often referred to as pressured speech.

RACING THOUGHTS
With racing thoughts, you feel like your thoughts are coming
faster than you can put them into words. You may have several
ideas at once, making it difficult to finish one thought before
starting another, or you may feel that your thoughts are unorga-
nized and difficult to make sense of. Sometimes this symptom is
referred to as a flight of ideas.

DISTRACTIBILITY
During a manic episode everything seems interesting, which
makes it difficult to focus or to pay attention to one thing at a
time. You may be easily distracted by internal experiences (such
as thoughts and ideas) or external events (whatever is going on
around you). You may also find that you can’t get through the
morning paper or your favorite TV show because your mind keeps
wandering off somewhere else. Distractibility can make it difficult
to get things done at work, school, or home.

INCREASED GOAL-­DIRECTED BEHAVIOR

In a manic episode you may find that you spend a lot of time
planning or participating in multiple activities. For example, you
may take on several new projects within a short time frame.
Ambition is a good thing, but when you’re feeling manic you may
take on several projects without taking the steps necessary to set
yourself up for success. You might skip getting educated

9
Bipolar Disorder: A Guide for the Newly Diagnosed

on a certain topic, gaining work experience, saving money and

budgeting, or finding the social support you need to accomplish
your goals. For example, you might use all of your savings to start
a law practice even though you don’t have a law degree and never
wanted to be a lawyer before.

PSYCHOMOTOR AGITATION
With mania, you may experience sensations of restlessness or
the feeling that you can’t sit still for a long period of time. You
may feel like pacing around a room or continually wringing your
hands even if you want to rest or sit down. This is termed psycho-
motor agitation because feelings of tension or restlessness can
cause excessive physical activity.

EXCESSIVE INVOLVEMENT IN PLEASURABLE

ACTIVITIES
In a manic episode you may participate in pleasurable activi-
ties that may not be safe or responsible, such as spending money
excessively, engaging in risky sexual activity, or making decisions
quickly without thinking through the consequences. For exam-
ple, you may abruptly leave on a vacation without notifying your
boss or spend a lot of money on things you can’t afford. In the
moment, these decisions may seem fun and exciting, but they
often lead to negative consequences down the road.

10
 Understanding Bipolar Disorder

HYPOMANIC EPISODES
Not all people who have bipolar disorder experience a manic
­episode. Some people experience fewer and less intense manic
symptoms for a shorter amount of time. This is called hypomania.
A hypomanic episode is defined as an abnormally high or irrita-
ble mood in combination with three or more symptoms of mania
lasting at least four days. The key difference between hypomania
and mania is that mania creates difficulties in a person’s life, such
as conflicts with employers or family members, reckless behaviors,
or financial problems. Hypomania is less severe, and while it is
clearly different from how you usually feel, you may not experi-
ence disruptions or problems in your daily life as a result of these
symptoms. Another difference is the length of symptoms. By defi-
nition, manic episodes must last at least one week, whereas hypo-
manic episodes may be as brief as four days. Determining the
difference between mania and hypomania can sometimes be
challenging, since it may be difficult to remember the intensity of
your symptoms and how long they lasted.

DEPRESSIVE EPISODES
The words “depression” and “depressed” are often used in the
media and in everyday conversations. However, psychologists and
physicians define a depressive episode as the presence of five or
more symptoms of depression (described below) experienced most
of the day nearly every day for at least two weeks. At least one of
the five symptoms must be depressed mood or loss of interest or

11
Bipolar Disorder: A Guide for the Newly Diagnosed

pleasure in activities (also known as anhedonia). Even though we

often think of depression as feeling down or blue, you can meet
the diagnosis for depression without feeling sad. In fact, people
with bipolar disorder commonly don’t experience sadness when
depressed, but instead have a sense of emotional emptiness or
indifference.

Depression Symptoms
The depressive symptoms of bipolar disorder are the same as
those seen among people who experience depression without
manic symptoms. When depressive symptoms occur in a person
who has never experienced manic or hypomanic symptoms, it is
called major depressive disorder or unipolar depression. However,
when people with bipolar disorder experience depression, it usu-
ally occurs more often, arises more quickly, and is felt more
intensely than unipolar depression. Therefore, it’s important to
educate yourself on how to recognize not only the highs of
mania, but also the lows of depression. Depression is defined by
a shift in mood that involves feelings of immense sadness, emp-
tiness, or worthlessness. You may also lose interest in your usual
activities or find that the things that usually make you feel good
don’t anymore, like going to the movies or spending time with
friends and family. Depression also includes experiencing some
of the symptoms described below.

12
 Understanding Bipolar Disorder

CHANGES IN EATING HABITS

You may gain or lose more than 5 percent of your body weight
in a month or experience an increase or decrease in appetite. For
example, you may find that you’re eating more than usual or that
you never feel hungry and must force yourself to eat because you
know your body needs food.

CHANGES IN SLEEP
You may experience insomnia, meaning you have trouble fall-
ing asleep or staying asleep. You may also find yourself having
difficulty getting out of bed in the morning or waking up early in
the morning and being unable to fall back asleep. Alternatively,
you may sleep more than usual which is called hypersomnia.

PSYCHOMOTOR AGITATION OR SLOWING

You may feel agitated, restless, or unable to sit still, as in
mania. But you could also experience the opposite. You could feel
extremely slowed down in your thinking, movements, or speech.
Sometimes this is called psychomotor retardation.

FATIGUE OR LACK OF ENERGY

You may feel exhausted, like all the energy has been drained
from your body. As a result, you may have difficulty doing things
that are usually easy for you or accomplishing things that nor-
mally don’t require much effort.

13
Bipolar Disorder: A Guide for the Newly Diagnosed

FEELINGS OF WORTHLESSNESS OR GUILT

You may feel like you’re inferior or as though you’re responsi-
ble for bad things that happen that might have nothing to do with
you. You may also find yourself feeling guilty about past events.

DISTRACTIBILITY OR INDECISIVENESS
You may have a hard time getting work done, remembering
things, or making decisions. Paying attention may feel extremely
difficult.

SUICIDALITY
You may feel as though your symptoms of mania or depres-
sion will last forever and that there is no hope. Thinking about
death, dying, or suicide is a very common experience for people
with bipolar disorder. It has been estimated that about one-­third
of people with this illness attempt to commit suicide at some
point in their lifetime (Chen and Dilsaver 1996). There are levels
of severity of suicidal thinking. Every level is a sign of serious
pain, but thinking about death or wanting to die doesn’t mean
that a person will commit suicide. It is important to talk openly
about these thoughts and experiences with your treatment pro-
viders so they can offer you help and support. Mental health pro-
fessionals usually start developing a safety plan to intervene
against a possible suicide attempt if you start thinking about how
you would take your own life.

14
 Understanding Bipolar Disorder

PERSONAL EXPERIENCES WITH

MOOD EPISODES
Here are two stories of people who have experienced mood epi-
sodes like the ones described above. Like we said before, people’s
experiences with bipolar disorder are varied. However, the follow-
ing stories will help give you a better idea of what a mood episode
may look like.

Sue’s Story: A Manic Episode

Sue is an accountant. In the middle of tax season she started
sleeping less in order to finish paperwork and found that she no
longer needed much sleep and still had plenty of energy to work.
In fact, she started sleeping only two hours a night and still found
that she had so much energy that she was easily distracted from
her work. She got extremely annoyed when several of her clients
told her she was talking too fast and that they couldn’t follow
what she was saying, so she decided to abandon her practice and
move to a different state in order to find new clients who were less
irritating. In the process of the move, she spent her life savings.

Joe’s Story: A Depressive Episode

Ever since his father passed away, Joe had found the holidays
challenging. From Thanksgiving until New Year’s he felt sad and

15
Bipolar Disorder: A Guide for the Newly Diagnosed

empty, slept all the time, and isolated himself from his friends and
family. The dishes piled up in the sink because he didn’t have the
energy to wash them. He didn’t have an appetite and had to force
himself to eat. Joe spent most of his time feeling guilty about
arguments he had with his father as a child. Throughout his
depression, he felt like he had no purpose in life.

TYPES OF BIPOLAR DISORDER

You may have heard treatment providers refer to bipolar disorder
with a number—­bipolar I or II—­or with the word “cyclothymia.”
This is because there are different types of bipolar disorder. Each
is defined by different levels of manic symptoms, and some also
include symptoms of depression. We will describe these diagnoses
below, but the key differences between the types of bipolar disor-
der are the severity and duration of symptoms.

Bipolar I
Bipolar I disorder is characterized by at least one manic epi-
sode during your lifetime. You need not have a history of depres-
sion to be diagnosed with bipolar I disorder. This may seem
confusing, since the word “bipolar” implies fluctuating between
two moods and the illness is sometimes referred to as manic-­
depressive disorder. Nonetheless, the only criterion for bipolar I
disorder is at least one episode of mania. Although it’s not required

16
 Understanding Bipolar Disorder

for the diagnosis, depression is very common in bipolar I. About

two-­thirds of people with bipolar I disorder experience a depres-
sive episode in their lifetime (Cuellar, Johnson, and Winters
2005), so in bipolar I disorder it is common to experience both
depressive and manic episodes.

Bipolar II
Bipolar II disorder is defined by experiencing both a hypo-
manic and a depressive episode. In other words, to meet the crite-
ria for bipolar II, a previous episode of depression is necessary,
along with symptoms of less intense mania lasting at least four
days. If a person has experienced both hypomanic and manic epi-
sodes, he is diagnosed with bipolar I disorder, not with bipolar II
disorder.

Cyclothymia
Cyclothymia is defined by a pattern of chronic and frequent
mood changes. These fluctuations are not as extreme as those
experienced in manic episodes. Rather, the diagnosis is based on
how much of the time some type of changed mood is present.
People with cyclothymia tend to feel either up or down at least
half of the time. Cyclothymia isn’t diagnosed until those mood
fluctuations have continued for a long time: one year for adoles-
cents and two years for adults.

17
Bipolar Disorder: A Guide for the Newly Diagnosed

THE EXPERIENCE OF BIPOLAR

DISORDER OVER TIME
Bipolar disorder is an episodic, recurrent illness. This means that
throughout your life, you might experience symptoms of mania or
depression, and then these symptoms will clear and you will expe-
rience periods of wellness. Often, this pattern tends to repeat
itself. Relapse refers to a new episode after your first episode of
mania or depression. Remission or euthymia refers to periods with-
out manic or depressive symptoms.
Even if you do everything you can to take care of yourself, you
may have relapses. However, they will be less frequent if you take
good care of yourself by doing things such as taking your medica-
tions, working with your treatment providers, getting enough
sleep, and identifying changes in your mood. The goal of treat-
ment is for you to learn how to minimize the chances of having
another episode. While there currently is no cure for bipolar dis-
order, many effective treatments exist (discussed in chapters 3
and 4). Thanks to these treatments, many people who in the past
would have spent a lot of time hospitalized can manage their ill-
ness and continue living their lives and achieving their goals.

THE BIOLOGY OF BIPOLAR

DISORDER
As we stated at the beginning of this chapter, bipolar disorder is a
biological illness. Although we know that bipolar disorder results

18
 Understanding Bipolar Disorder

from biological changes, there are currently no medical tests, such

as brain scans, blood tests, or genetic tests, that can confirm a
bipolar diagnosis or the likelihood of developing the illness.
Stressors such as childhood trauma, poor family relationships,
and sleep deprivation can bring on or worsen symptoms, but they
don’t cause bipolar disorder. In this section, we’ll discuss the bio-
logical changes that are believed to contribute to the develop-
ment of this illness.

Changes in Brain Chemistry

Bipolar disorder is an illness related to the chemistry of the
brain. Research has shown that among those with bipolar disor-
der, some neurotransmitters—­the chemicals that carry informa-
tion throughout the brain and nervous system—­don’t appear to
work properly. Two important neurotransmitters that are dis-
rupted in bipolar disorder are dopamine and serotonin. Dopamine
is related to the reward system and plays a role in wanting some-
thing, such as achieving an important goal. Serotonin is related to
mood regulation and helps keep you from having too many highs
and lows. Problems with the dopamine and serotonin systems are
believed to cause changes in mood and behaviors. Medications
that help balance mood work by restoring these systems in the
brain. (We’ll discuss these medications in chapter 3.)
Areas of the brain that regulate mood and the reward system
are also affected in bipolar disorder. As a result, it becomes more
difficult to modify your mood in response to your situation. It may
be easier to think of these parts of your brain as a thermostat for

19
Bipolar Disorder: A Guide for the Newly Diagnosed

your mood. In your home, the thermostat helps keep the tempera-
ture of a room stable by making changes in response to the envi-
ronment. If your house is hotter than the set temperature, the
thermostat will turn on the air-­conditioning, and if your house is
colder, it will turn on the heat. Your brain’s mood thermostat is in
charge of keeping your mood stable and appropriate to your
situation.

Genes and Bipolar Disorder

Whether people develop bipolar disorder can be highly influ-
enced by their genes. The heritability of this illness is 70 to 80
percent (Gurling et al. 1995), which means that 70 to 80 percent
of the risk of developing bipolar disorder is genetic. It also means
that about 20 to 30 percent of the risk of developing bipolar dis-
order is driven by factors other than genes. We know that bipolar
disorder involves many genes, but researchers are still trying to
identify the particular combinations of genes involved. Therefore,
it’s difficult to pinpoint the exact cause of developing this illness
for a particular person.
Bipolar disorder is thought to result from a combination of
genetic vulnerabilities and environmental influences. In some
environments a person may not develop symptoms, despite hav-
ing the genes for bipolar disorder. In other environments, the
genes for bipolar disorder may be expressed, showing up in the
form of symptoms.
About 1 percent of people have bipolar I disorder, and about
4 percent of people experience other types of bipolar disorder

20
 Understanding Bipolar Disorder

(bipolar II or cyclothymia; Merikangas et al. 2007). Even though

the disorder is genetically influenced, most children who have a
parent with bipolar disorder will not develop the disorder. Having
a parent with bipolar disorder increases the risk for bipolar disor-
der, on average, fourfold to sixfold (Nurnberger and Foroud
2000). Needless to say, you can’t choose whether your child will
inherit the disorder, just like you can’t choose the color of your
child’s eyes. However, you can learn strategies to provide a sup-
portive environment if your child does develop the illness. You
can also help your child learn as much as possible about how to
regulate moods.
Even if you don’t have a history of this illness in your family,
changes that occur in development before birth can impact your
genes and the likelihood that you’ll develop an illness like bipolar
disorder. In addition, it’s possible that family members with expe-
riences similar to yours who may have had bipolar disorder but
were never diagnosed.
Genetics and neurotransmitters can be scary topics to learn
about; people sometimes feel like this information implies that
they have no control over their moods or their lives. Some people
also mistakenly believe that because bipolar disorder has a strong
genetic component, it cannot be helped. This isn’t true. By mak-
ing it a priority to learn more about your illness and by doing
things like reading this book, you are taking charge of your life
and learning skills to manage the illness and stay healthy. You’re
also putting yourself in a position to educate your family members
and friends about bipolar disorder.

21
Bipolar Disorder: A Guide for the Newly Diagnosed

COMMON CO-­OCCURRING
DISORDERS AND SYMPTOMS
Sometimes when you have an illness you may also experience
other disorders or symptoms. Two or more disorders that occur at
the same time are known as comorbid disorders. Comorbid disor-
ders that tend to occur with bipolar disorder can make it more
difficult to manage your symptoms. However, educating yourself
about these additional disorders or symptoms can help you pro-
long periods of wellness.

Other Mental Illnesses

More than 50 percent of people with bipolar disorder experi-
ence severe anxiety (Simon et al. 2004). In addition, 60 percent
of people with bipolar disorder have recurrent problems with or
become addicted to alcohol or drugs at some point in their life-
time (Regier et al. 1990). People with bipolar disorder may have
the most severe problems with anxiety, alcohol, or drugs during
mood episodes. When you feel manic, you may be particularly
vulnerable to excessive drug or alcohol use because of the ten-
dency to get overly involved in pleasurable activities or sensation
seeking. Other problems that tend to co-­occur with bipolar disor-
der are eating disorders (McElroy et al. 2001) and attention defi-
cit/hyperactivity disorder (Nierenberg et al. 2005).
Sometimes people with bipolar disorder report strange or
unusual sensations called psychotic features. This may sound scary,
but it’s actually very common. Psychotic features typically involve

22
 Understanding Bipolar Disorder

seeing or hearing something that others cannot (hallucinations)

or having beliefs that aren’t supported by facts (delusions).
Examples of delusions would be thinking that you’re fluent in a
language that you haven’t studied before or believing that you’ve
created an equation that will solve a financial crisis even though
you’ve never studied economics. In bipolar disorder, these psy-
chotic experiences occur during manic or depressive episodes and
then clear when the mood symptoms get better.
You can learn more about these comorbid mental disorders
by talking to other people who have had such experiences or by
taking a class on symptoms, coping strategies, and treatment
options. This is often referred to as psychoeducation, and we will
discuss it further in chapter 4. You may also find some of the
books and websites listed in the Resources section helpful.

Other Medical Illnesses

Bipolar disorder is also related to high rates of medical ill-
nesses. Cardiovascular conditions such as heart disease, high
blood pressure, and elevated cholesterol occur much more fre-
quently in people with bipolar disorder than in the general popu-
lation (Kupfer 2005). In addition, there is an increased risk for
weight gain, often due to side effects of medications prescribed to
treat mood fluctuations. Therefore, it’s helpful for people with
bipolar disorder to communicate regularly with their doctors to
find a balance in their medications that allows for greater benefits
(stable mood and fewer mood episodes) and fewer negative side
effects, including weight gain. If you experience any of these

23
Bipolar Disorder: A Guide for the Newly Diagnosed

comorbid medical illnesses or symptoms, discuss them with your

treatment team to learn more about how you can manage your
physical health.

MYTHS ABOUT BIPOLAR DISORDER

Now that you’ve learned the basics about what bipolar disorder is,
what it looks like, and what we know about its causes, you have
the knowledge to dispel some of the common myths about bipolar
disorder and educate others about this illness. Let’s take a look at
some of these myths.

Myth: If I were stronger, I wouldn’t have this illness.

Reality: We know that bipolar disorder is a biological illness. It is

largely caused by genetics and a chemical imbalance in the parts
of the brain that help regulate mood. Bipolar disorder isn’t a
weakness; it’s linked to actual biological changes in your body.

Myth: I’ll never be able to reach my goals because I have bipo-

lar disorder.

Reality: Now that more is known about what causes bipolar dis-
order and helpful treatments have been developed, people with
bipolar disorder often live healthy, fulfilling lives and continue to
meet their life goals.

24
 Understanding Bipolar Disorder

Myth: Something I did caused this illness.

Reality: Because bipolar disorder is a biological illness, nothing

you did caused you to develop symptoms. Although factors like
stressful or exciting life events or sleep deprivation may make it
more likely that you’ll experience symptoms, they don’t cause the
illness.

Myth: I can control this illness without medications and

doctors.

Reality: While you hold the power to manage your illness, taking
medications and working with a treatment team will help you
cope with symptoms, lengthen your periods of being symptom-­
free, and decrease the number and severity of future mood epi-
sodes. That is why we highly recommend working with mental
health professionals if your goal is to recover and stay well.

SUMMARY
Bipolar disorder is a biological illness that affects your ability to
regulate your mood. To receive a bipolar disorder diagnosis, a per-
son must experience a combination of manic symptoms for a cer-
tain period of time. Many people with bipolar disorder also
struggle with depressive symptoms. Since bipolar disorder is a
recurrent disorder, episodes of mania or depression tend to repeat

25
Bipolar Disorder: A Guide for the Newly Diagnosed

over time. Identifying the symptoms that are most common for
you and actively engaging in treatment will help to extend peri-
ods of wellness between mood episodes. Although there are mis-
conceptions about the causes and symptoms of bipolar disorder,
many people with this diagnosis prove these myths wrong by liv-
ing meaningful and satisfying lives.

26
 Chapter 2

c
c

Receiving a
Diagnosis and
Finding Help

Receiving a diagnosis of bipolar disorder, or any other illness for

that matter, is often challenging and may bring up many different
emotions. You may feel scared because bipolar disorder is a life-
long illness, or you may feel relieved because you’ve struggled with
symptoms for a long time and now your experiences have a name.
A diagnosis is the first step in receiving treatment that will help
you take control of your mood and maintain longer periods of
wellness. In this chapter, we’ll help you prepare to take that first
step. We’ll provide you with resources to help you find treatment
Bipolar Disorder: A Guide for the Newly Diagnosed

providers and prepare for that first appointment, including ques-

tions your clinician may ask. We’ll also try to give you an idea of
what to expect after receiving a diagnosis or beginning
treatment.

FINDING PROFESSIONAL HELP

A variety of helpful resources and professionals are available to
provide support for those with bipolar disorder. Some people
decide to work with multiple skilled professionals who specialize
in various components of their treatment. An example of a treat-
ment team may include a psychiatrist who prescribes medication,
a therapist who offers weekly support, and a caseworker who helps
coordinate services. An ideal approach is to find treatment pro-
viders who already work together, preferably in the same cen-
ter. This will help ensure that your treatment team works closely
together to provide the best care. Often though, the treatment
team approach isn’t available in a given area, or you may find that
you really like one provider who isn’t part of a larger team. If
members of your treatment team don’t work in the same place, it’s
a good idea to provide written permission for members of your
treatment team to talk to each other. This way, they can work
collaboratively to provide the best quality of care. The goal is to
work with people you feel comfortable with who are also able to
help you navigate the variety of available treatment options so
you can make informed decisions about your health care. Finding
the treatment providers who are right for you can take time, but

28
 Receiving a Diagnosis and Finding Help

in a way this is good news because it means you have a lot of

options.

Types of Mental Health Professionals

Doctors, psychiatrists, and therapists, oh my! Selecting a
treatment provider can be confusing if you don’t know the differ-
ence between the types of services and help various mental health
professionals can offer. When researching possible treatment pro-
viders, pay special attention to their degrees, training, and spe-
cialties. This information will help determine the kind of help
they can offer and what types of treatment services they provide.

MEDICATION PROVIDERS
Psychiatrists, who hold medical degrees such as MD, are treat-
ment providers who can prescribe medications, much like your
primary care physician. However, they also have specialized train-
ing in diagnosing and treating mental illness. Since most people
with bipolar disorder decide to take medication to help treat their
symptoms and extend periods of wellness, it’s likely that you’ll
have a psychiatrist on your treatment team. Typically, you’ll see
your psychiatrist about once a month or less for medication
checkups, or sooner if you have a medication emergency.
Alternatively, you may choose to receive medication advice and
prescriptions from your primary care physician. Although this is
often a more convenient and affordable way to get medications,
these doctors don’t have the specialized training in mental illness
that psychiatrists receive as part of their medical training.

29
Bipolar Disorder: A Guide for the Newly Diagnosed

THERAPY AND SUPPORT

As we’ll discuss in chapter 4, there are a variety of different
types of therapy, and several that are especially effective for bipo-
lar disorder. Therapist is a term used to describe anyone who pro-
vides talk therapy (for example, a psychologist or social worker).
Just as there are different therapy styles, therapists have different
training backgrounds and experience. You’ll have to do some
research to find therapists in your area who are skilled and knowl-
edgeable about bipolar disorder; however, we have provided some
information to help you in your search, both in this chapter and
in the Resources section.
Psychologists, who hold degrees such as PhD or PsyD, are doc-
tors who have received extensive training in mental illness, just
like psychiatrists, but their specialty is in therapy, not medication.
In some states (currently just New Mexico and Louisiana), psy-
chologists can receive additional training that allows them to pre-
scribe medications. Check with local psychologists to see if you
can receive therapy and medication services from one provider.
Social workers, marriage and family therapists, and caseworkers,
who hold degrees such as MSW, MFT, or LCSW, also receive
specialized training in working with people with mental illness
diagnoses. They can offer therapy and support and can also help
with navigating government and community services.
Nurse practitioners, who hold degrees such as NP-­C, ARNP,
CNP, and PMHNP, can also offer psychological services and
often work closely with psychiatrists to coordinate care. They

30
 Receiving a Diagnosis and Finding Help

receive additional training in diagnosing and treating both medi-

cal and mental illnesses and can also prescribe medications.
Although it is important to know that they have less specialized
training in medications than psychiatrists, many nurse practitio-
ners are more available at short notice in times of crisis.

Getting Referrals and Recommendations

Finding a mental health professional can be relatively easy if
you know where to look. If you have insurance, you may want to
start by researching the services and treatment providers covered
by your insurance plan. You can also learn about services in your
area through organizations you trust. The Depression and Bipolar
Support Alliance (DBSA) has created a Find a Pro search engine;
it can help you find treatment providers in your area who have
been recommended by other people with bipolar disorder (find-
apro.dbsapages.org). The National Network of Depression Centers
website is another resource that can help you find organizations
in your area that specialize in the treatment of depression (www
.nndc.org/centers-of-excellence). University hospitals and Veterans
Affairs medical centers often have specialized clinics that can
offer care to individuals with bipolar disorder. Finally, resources
for finding therapists in your area are also available on the web-
sites of professional psychological organizations, such as the
American Psychological Association (locator.apa.org) and the
Association for Behavioral and Cognitive Therapies (abct.org).

31
Bipolar Disorder: A Guide for the Newly Diagnosed

CHOOSING A BIPOLAR DISORDER

SPECIALIST
There’s a lot to think about before making that first call to sched-
ule an appointment with a mental health professional. Take some
time and research all of your options before making a decision
about whom you’d like to have on your team. The choice to get
help and whom you work with is yours, so set yourself up for suc-
cess by finding treatment providers who support and understand
you. If you are restricted in your treatment options because of
your insurance plan, finances, or availability of resources, it is still
important to research the providers who are available to you.
Learning more about the kind of treatment team you want may
help you feel more comfortable, prepared, and in control when
you show up for the first appointment.
Also remember that you have options. When beginning your
search, it’s a good idea to meet with a couple of different providers
before selecting a psychiatrist or therapist. Meeting them in per-
son will give you a better idea of who would be a good choice for
you. We recommend working with a treatment team that can
offer both medication and therapy services. As you’ll discover as
you read further, a combination of medication and psychosocial
treatments is often the most effective way to prevent future mood
episodes and extend periods of wellness.

32
 Receiving a Diagnosis and Finding Help

INVOLVING YOUR INSURANCE

COMPANY
If you have insurance, you’ll also need to decide whether you
want the insurance company to help pay for services. However,
some insurance companies limit the number of visits they’ll cover,
so if you’re looking for long-­term care, you may not want to start
treatment with someone who will be able to provide treatment for
only as long as your insurance company allows.
The services that are paid for by your insurance company will
also be on record, which means that, just as with any other ill-
ness, anyone who is associated with the treatment center or insur-
ance company could potentially have access to these files, your
diagnosis, and the treatment you received. It is important to
always read the privacy notices you receive when you begin treat-
ment with a new provider or at a new health center. These
describe how your information is stored and who can access it. If
you pay for services yourself, you have more freedom about where
you receive treatment, and possibly more privacy regarding your
treatment history. Unfortunately, private mental health services
tend to be more expensive, so your choices and treatment might
be restricted by which services you can afford.

SCHEDULING AN APPOINTMENT
After selecting the treatment providers you’d like to consult with,
the next step is scheduling an appointment. Whomever you talk

33
Bipolar Disorder: A Guide for the Newly Diagnosed

to when scheduling the appointment will probably ask you some

brief questions about the services you’re looking for and why
you’re currently looking for support; for example, “When did you
first notice there was a problem?” and “What have you done in
the past to help deal with these experiences?” These questions
will vary depending upon whom you call. If you’re contacting
someone from a large medical group, such as Kaiser Permanente,
this phone call may be short. If you’re contacting someone at a
small center or community clinic or an individual, such as a men-
tal health professional in private practice, the person who takes
your call may collect more information to determine whether
they can provide the services you’re looking for before scheduling
an appointment.
It may take some time to schedule an appointment if you
have to leave messages or play phone tag before getting someone
on the phone. Then, when you do make contact, you may not be
able to schedule an appointment right away depending on avail-
ability or finding a time that works with your schedule. This can
be frustrating. If this occurs, try to generate creative solutions and
adjust your schedule as needed to take advantage of an available
appointment time. You may need to take a day off of work, arrange
for child care, or otherwise free up time in your schedule.
You may also find that there are no openings with a particu-
lar doctor or center. If this is the case, they will probably give you
referrals to other agencies and treatment providers in the area.
They may also offer to place you on a waiting list and contact you
when they have availability. Although this is less than ideal, it’s
probably worth doing. While you wait, you can continue

34
 Receiving a Diagnosis and Finding Help

to contact other treatment providers, using their referrals as a

starting point. Since scheduling an appointment may take some
time, it is helpful to contact multiple treatment providers whom
you may be interested in working with.

PREPARING FOR THE APPOINTMENT

The goal of the initial consultation with a bipolar disorder spe-
cialist is for the care provider to learn more about your history
and experiences. This first session with a doctor or therapist is
often the longest. For example, you may need to arrive early to
read and complete paperwork, such as consent forms and the pri-
vacy policies we mentioned earlier. The provider will ask you
questions about your symptoms, the history of your concerns, and
any family history of mental illness. If you’ve struggled with mood
symptoms for a long time, you will probably need more than one
session to cover all of this material with a new treatment provider.
Taking time to think about your history before your appointment
will help move the process along.
The first appointment is also a time for you to ask questions
about the services that will be provided and any concerns you
may have regarding your treatment or health. To prepare for the
appointment, it would be a good idea to read chapters 3 and 4 of
this book so you are more informed about your medication and
treatment options.

35
Bipolar Disorder: A Guide for the Newly Diagnosed

Information You May Want to Bring

To help prepare for this first appointment, spend some time
thinking about your experiences with each of the symptoms dis-
cussed in chapter 1, both currently and throughout your life. Did
any of the symptoms we talked about stand out to you? Have your
moods, behaviors, or thoughts ever caused you problems or made
it more difficult for you to get through the day? The mental health
professional you meet with will want to hear about these chal-
lenges, so write them down or start a list you can bring with you
to this first session. You can also talk to family members about
concerns they may have or things they’ve noticed that would be
helpful for you to talk about with your treatment provider. If this
isn’t your first time receiving mental health services, you’ll also
discuss your previous treatments so your provider can learn more
about which medications and treatments have helped in the past.
If you have taken medications for mental health issues in the past,
bring a list of those medications with you. If possible, provide a
list of what dosages you took of each medication, how much relief
you noticed, and whether you experienced any side effects. The
more you can share about previous treatments, the better.

Bringing a Support Person

Meeting a treatment provider for the first time can be stress-
ful, so you may want to bring someone along for support. If there’s
someone who you feel understands you, who has been there for
you while you struggled with mood symptoms, or who offered

36
 Receiving a Diagnosis and Finding Help

help along the way, you may want to bring this person with you to
the appointment. It’s fine to ask mental health professionals if
they would like you to bring another person to join the initial
consultation. In fact, it is often helpful for treatment providers to
hear another person’s perspective.
Providers may also ask to talk to family members or signifi-
cant others later in treatment if you agree that it might help your
treatment. If bringing someone to the actual session isn’t an
option, you can always bring someone along for support before
and afterward. Since waiting rooms are often small, we recom-
mend bringing only one person with you.

DURING THE APPOINTMENT

As mentioned earlier, the first time you meet with a treatment
provider you’ll have to answer important questions about your
background and experiences. The information you provide in this
session will help your treatment provider learn more about you
and determine whether what you describe is consistent with a
diagnosis of bipolar disorder. Don’t be dismayed if it feels like the
initial session doesn’t help. It can sometimes take several sessions
for a mental health professional to conduct a comprehensive diag-
nostic interview and carefully collect all the information neces-
sary to make a diagnosis and design a good treatment plan.
Although it may not feel like it, the time it takes for care provid-
ers to learn about your experiences is an essential component not
only of your diagnosis but also of treatment.

37
Bipolar Disorder: A Guide for the Newly Diagnosed

Testing and Assessments

As mentioned, there are no medical tests (such as brain scans
or blood tests) that can confirm a diagnosis of bipolar disorder.
Instead, treatment providers will ask you lots of questions about
your experiences and the length of time you’ve had symptoms to
determine whether the frequency, severity, and timing of your
mood symptoms meet the diagnostic criteria for bipolar disorder.
You may also be referred to a physician for a physical exam and
thorough medical history in order to rule out other illnesses that
might be causing your symptoms; for example, thyroid problems
can cause mood swings.

Questions You May Be Asked

To help you prepare for your appointment, we’ll list some of
the questions that mental health professionals will ask to learn
more about your mood, symptoms of mania and depression, and
other symptoms or concerns. While some of these questions may
seem invasive or embarrassing, it’s important to answer openly
and honestly so the care provider has an accurate picture of your
experiences and can offer you the most effective treatments.
Think about how you would answer these questions given your
past and current experiences:

• Has there been a period of time when you felt down

or depressed? How long did that last? Tell me more
about that experience.

38
 Receiving a Diagnosis and Finding Help

• How about the opposite: Have you ever felt so good,

high, or excited that others thought you weren’t your
usual self or felt concerned about you? Describe what
else was going on during that time.

• When you were feeling unusually sad or elated, did

you notice any changes in your sleep? What about
your appetite?

• Have there been times when you felt unusually

irritable—­more than just waking up on the wrong
side of the bed? Did you find yourself starting argu-
ments with your friends or family members? How
about strangers?

• When you were feeling irritable or unusually high, did

you or others notice any changes in the way you
talked? For example, did you talk louder or faster? Was
it hard for others to get a word in? Did you feel like
your thoughts were changing so fast that it was hard
for you to communicate what you were thinking?

• What was your energy like? Did you lie in bed a lot
or feel slower than usual? What about the opposite:
Did you have lots of energy? Did you start a lot of
projects? Did you have a lot of goals you were work-
ing toward?

• How was your self-­esteem during these times? Did

you think you were better, worse, or about the same
as others?

39
Bipolar Disorder: A Guide for the Newly Diagnosed

• Have you felt nervous or anxious lately?

• How often do you consume alcohol? How much?

How often do you use nonprescribed drugs, such as
marijuana, cocaine, or heroin? How does using drugs
or alcohol affect your mood or symptoms?

• Do you have any other concerns?

Family History
As discussed in chapter 1, genes can influence your likeli-
hood of developing bipolar disorder. Learning more about your
family history of mental illness, particularly any history of bipo-
lar disorder or depression, will provide your treatment team
with very helpful diagnostic information. You may not know of
any family members who received an official diagnosis, but your
clinician can still gather useful information by asking questions
such as “Do you know of anyone in your family who experiences
similar problems with mood? Are there family members you’ve
worried about because you haven’t heard from them for a while,
or who seem different from the rest of the family in some way?”
Questions like these will help you and your treatment provider
consider whether other people in your family have struggled
with their mood, even if they didn’t necessarily have a mental
illness diagnosis.

40
 Receiving a Diagnosis and Finding Help

Questions You Might Want to Ask

The first appointment with a mental health professional is
also an opportunity for you to ask questions and receive answers.
Check in with yourself and make sure you feel comfortable work-
ing with this treatment provider. Feeling like you click and that
you can confide in this person is often a good indicator that
you’ve found a good match. However, it may take more than one
session to determine this.
In your initial meetings, be sure to save some time to address
any questions or concerns that come up during your time together.
Here are some questions you may want to ask:

• What is your experience with treating bipolar

disorder?

• What treatment do you recommend? How well do

you think it will work?

• What other treatment options are available?

• How often will we meet? How long will our appoint-

ments last?

• How can I reach you in case of an emergency?

• What should I do if I forget to take my medication or

miss an appointment?

• Is there a generic form of my medication?

41
Bipolar Disorder: A Guide for the Newly Diagnosed

AFTER YOUR DIAGNOSIS

Getting a diagnosis of bipolar disorder is the first step toward
receiving treatments that can offer relief from symptoms and get-
ting support for staying well. The goal of a diagnostic interview is
to help you put together the pieces of your symptoms in a way that
helps you understand your previous experiences in a new light.
A diagnosis can set you on a path that can help you lead a gener-
ally happy and healthy life.

The Good and Bad Aspects of

Receiving a Diagnosis
Learning that you have bipolar disorder can be challenging.
You may have a lot of questions or fears about the illness. Talking
to your treatment team about your concerns and worries can help
make this difficult time easier. Unfortunately, there are still a lot
of myths and misconceptions about mental illness, often perpetu-
ated by the media and possibly believed by people you know.
Sometimes people with bipolar disorder are portrayed as unpre-
dictable, violent, or unable to succeed in life. The good news is
that there is a lot of research showing that treatments such as
medications and therapy are helpful for people with bipolar disor-
der and that these myths are false.
Although it may be hard to see at first, a lot of good can come
from a bipolar diagnosis. Once you learn skills for managing your
mood, your symptoms won’t feel as overwhelming, and you may
be less likely to engage in activities that have caused you problems

42
 Receiving a Diagnosis and Finding Help

before, such as overspending or engaging in risky sexual behavior.

People with bipolar disorder can be just as successful as people
without mental illness, and staying healthy maximizes the
chances of this being the case for you. People with bipolar disor-
der are also often very creative. Being able to think outside the
box can help you come up with a lot of different solutions to
problems—­including those in your own life. Most importantly,
the good aspects of bipolar disorder don’t go away with treatment.
Treatment simply helps you to manage your illness so you can
continue to build a good life for yourself. We’ll discuss positive
traits associated with bipolar disorder in chapter 8.

The Next Steps

After your initial meeting with a mental health professional,
the next step is to think about whether you want to continue to
meet with this person and receive regular treatment. The deci-
sion is yours, so if you don’t feel heard, comfortable, or supported,
you may want to continue your search. If you have concerns, you
may also want to bring them up with the care provider before
deciding to work with someone else. However, if you don’t feel
like you can talk openly with the treatment provider, that may be
a sign that this isn’t the best treatment relationship for you. If at
any time you decide that you aren’t satisfied with your treatment
provider or that this person cannot offer the quality of care you’re
looking for, don’t feel guilty about exploring other options, even if
you’ve already started treatment with that provider. A good place
to start is by raising your worries, to see if you can improve your

43
Bipolar Disorder: A Guide for the Newly Diagnosed

relationship with the provider. Your right to receive excellent care

is more important than protecting the feelings of mental health
care providers. Once you decide on a treatment provider or team,
you can begin to learn more about the treatments that are avail-
able and start working collaboratively to decide which treatments
might be most helpful for you.

SUMMARY
Finding a treatment provider can take time and feel overwhelm-
ing, but it’s an important first step in receiving a diagnosis and
getting professional support. There are many options and
resources available to you, so take some time to really research
the professionals in your area and find one, or a team, that feels
right to you. To prepare for the first session with a mental health
professional, it’s helpful to think back on your experiences
throughout life and the symptoms discussed in chapter 1. Share
this information in your initial appointments to help treatment
providers learn more about your experiences and determine
whether you meet the diagnostic criteria for bipolar disorder.
Working with your treatment team can help you manage the con-
cerns you might have after receiving a bipolar disorder diagnosis.
Although it’s natural to have some fears, a diagnosis can also help
you understand your past experiences. It can also be a source of
hope, as you can now receive treatments that have been shown to
help manage the ups and downs of mood that constitute bipolar
disorder.

44
 Chapter 3

c
c

Medications

Medication is the most effective treatment for managing symp-

toms of bipolar disorder and extending periods of wellness
(American Psychiatric Association 2002). When you have fewer
mood episodes, you can more effectively work toward your goals,
strengthen your relationships with friends and family members,
and feel balanced and in control. In addition to medication, psy-
chosocial treatments (discussed in chapter 4) can also help reduce
symptoms and improve quality of life. In this chapter, we’ll dis-
cuss the benefits and side effects of medications approved for
treating bipolar disorder and answer some common questions
people have about taking medications.
In bipolar disorder, medications are used to relieve acute
symptoms of mania or depression. Since mood episodes tend to
Bipolar Disorder: A Guide for the Newly Diagnosed

reoccur, it’s often important to take medications even when you

aren’t manic or depressed. This is called maintenance treatment.
Learning more about medications will help you become an edu-
cated consumer so that you can actively participate with your
treatment team in fine-­tuning this aspect of your treatment.

THE PROS AND CONS OF TAKING

MEDICATIONS
It’s completely normal to have concerns about long-­term medica-
tion treatment. As with any illness and treatment, it’s important
to educate yourself on the pros and cons of taking medications to
treat bipolar disorder. The goal of a good medication plan is to
maximize benefits (symptom relief) and minimize costs (side
effects). Although medications may help you experience fewer
symptoms and mood episodes, they may also cause some unwanted
side effects, such as weight gain and fatigue, and they may require
certain dietary restrictions. As a consumer, it’s your job to weigh
the costs and benefits and work with your doctor to find the type
of medication and dosage that works best for you. Unfortunately,
this often takes time and some trial and error. You may have to
try a variety of medications before you find the right one.
Even with all of the benefits of medication, many people strug-
gle with whether to take them and whether to stay on them for long
periods. Some medications are expensive; however, most drug com-
panies have programs for receiving medications at a lower cost.
Another issue is that sometimes it takes several weeks before you

46
 Medications

feel the benefits of a medication, and you may actually experience

side effects that make you feel worse before you start feeling better.
Most importantly, realize that there’s no guarantee that med-
ication will relieve all of your symptoms. Even if you take your
medications regularly, there is a chance that you may relapse or
experience ongoing mild symptoms. These are all important pos-
sibilities to consider when deciding whether to take medications,
and there’s a good chance that you can think of additional items
to add to that list. The good news is, there are coping strategies
that will help make the downsides of medication more manage-
able, and we’ll describe some of them below.

FDA-­APPROVED MEDICATIONS FOR

BIPOLAR DISORDER
Medications for bipolar disorder work by increasing the function
of neurotransmitters, the chemicals in the brain that help regu-
late mood (discussed in chapter 1). In this section we’ll discuss
medications approved by the Food and Drug Administration
(FDA). The FDA is the U.S. federal agency responsible for ensur-
ing that medications provide benefits and are safe for use by the
general public. To be approved by the FDA, a drug must go
through several stages of review, including tests comparing the
drug to a placebo (a sugar pill) to make sure there’s evidence that
it works better than not taking medication.
Unfortunately, people sometimes advertise or push treat-
ments with no scientific support or FDA approval. For example,

47
Bipolar Disorder: A Guide for the Newly Diagnosed

you may see advertisements for natural or herbal remedies as sub-

stitutions for medications prescribed for bipolar disorder. If you
use treatment strategies that haven’t been tested, you run a higher
risk of having future mood episodes. Using only treatments that
have been approved by the FDA will ensure that you’re taking
medications that researchers have carefully studied and that are
known to be effective in preventing symptoms and relapse.
The medications currently available for bipolar disorder aren’t
perfect. The good news is, there’s hope on the horizon. Scientists
are constantly working to develop new medications that will be
more effective at decreasing symptoms with fewer side effects. We
have every expectation that this will bring more relief in the
future. To keep yourself updated on newly approved medications,
or if you have questions about a medication that this book doesn’t
address, visit the FDA website (www.fda.gov) or talk to your
treatment providers.

Mood Stabilizing Medications

Mood stabilizers are medications that reduce symptoms of
mania and depression and help keep your mood balanced between
episodes. Lithium carbonate, often referred to as lithium, is the
most commonly used mood stabilizer. Lithium works best for
people who have had a manic episode (bipolar I disorder;
­
American Psychiatric Association 2002). It’s helpful for reducing
acute manic symptoms and as a maintenance treatment during
periods of wellness. When people are taking lithium, they are also
less likely to attempt suicide. In other words, it saves lives. Some

48
 Medications

people experience side effects from lithium that can include trem-
ors, nausea, weight gain, fatigue, dehydration, dry mouth, diar-
rhea, and low levels of thyroid hormones. When taking lithium,
you’ll have to moderate your salt intake so you don’t become
dehydrated.
As with all medications, it’s important to find the dose that
works for you. This is particularly important with lithium because
if you take too little, it’s ineffective, and if you take too much, you
can develop lithium toxicity. Symptoms of lithium toxicity include
fatigue, slurred speech, and severe tremors. To avoid this, routine
blood tests are used to monitor the level of lithium in your blood.

Antiseizure Medications
Antiseizure medications, or anticonvulsants, are an alternative
type of mood stabilizer often used to treat bipolar disorder.
Sometimes they’re used when people experience too many side
effects from lithium. Carbamazepine (brand name Tegretol), val-
proic acid (brand name Depakote), topiramate (brand name
Topamax), and lamotrigine (brand name Lamictal) are some
commonly prescribed antiseizure medications. General side effects
can include sedation, nausea, and upset stomach. Topiramate is
often prescribed in combination with other mood stabilizers to
help offset the side effect of weight gain, but it is associated with
more attention, concentration, and memory impairments than
other drugs used to treat bipolar disorder (Chengappa et al. 2001).
Lamotrigine is most effective for treating depressive episodes in
bipolar disorder, helps improve cognitive functioning (Khan et al.

49
Bipolar Disorder: A Guide for the Newly Diagnosed

2004), and is often prescribed to pregnant women who have bipo-

lar disorder (Ornoy 2006). Side effects of lamotrigine can include
dizziness, tremors, headache, nausea, and rashes.

Antipsychotic Medications
As discussed in chapter 1, psychotic features (hallucinations
or delusions) can be a common experience for people in acute
manic or depressive episodes. Antipsychotic medications, which are
also called neuroleptic medications, are helpful in reducing psy-
chotic symptoms and lowering irritability, and they can be the
fastest way to treat acute manic episodes (American Psychiatric
Association 2002). Doctors often prescribe antipsychotic medica-
tions when people with bipolar disorder are hospitalized, and
some people may continue to use these medications as a mainte-
nance treatment.
There are two main categories of antipsychotic medications,
and they differ by when they were created and how they interact
with the brain. Chlorpromazine (brand name Thorazine) and
haloperidol (brand name Haldol) are commonly referred to as
first-­generation antipsychotic medications. These medications are
just as effective at treating symptoms as newer, second-­generation
antipsychotics. They are often cheaper, but they can have some
troubling side effects, including dry mouth, sedation, constipation,
rigidity, restlessness, and, if used long-­term, tardive dyskinesia, an
irreversible condition that involves abnormal mouth movements.
In an effort to decrease the negative side effects of first-­
generation antipsychotic medications, scientists developed the

50
 Medications

second-­generation antipsychotic medications, which include ris-

peridone (brand name Risperdal), olanzapine (brand name
Zyprexa), quetiapine (brand name Seroquel), and aripiprazole
(brand name Abilify). These medications are more commonly used
to treat bipolar disorder than first-­generation antipsychotic medica-
tions but also tend to be more expensive. Side effects associated
with second-­generation antipsychotic medications include weight
gain and, unfortunately, some of the same side effects as the first-­
generation medications, such as rigidity, restlessness, and sedation.

Antidepressant Medications
It was once thought that antidepressants (medications com-
monly prescribed to treat depressive disorders and anxiety) were
necessary to treat bipolar depression. Research now shows that
mood stabilizers alone can help with both mania and depression, so
taking an antidepressant might not be necessary (Sachs, Sylvia,
and Kund 2009; Altshuler et al. 2009). For many people with bipo-
lar disorder, taking an antidepressant without a mood stabilizer can
cause a manic episode (Ghaemi, Lenox, and Baldessarini 2001).
This risk is lower if antidepressants are taken in combination with
other mood stabilizing medications (Sachs et al. 2007). That said,
if your mood is stable, don’t be alarmed if you’re taking antidepres-
sants without a mood stabilizer. This means that the antidepres-
sant you’re taking seems to be working, so it isn’t necessary to
switch medications. Since finding the right medication takes time,
it’s best not to change a medication if it is working for you. If you do
have concerns, be sure to discuss them with your treatment team.

51
Bipolar Disorder: A Guide for the Newly Diagnosed

There are several classes of antidepressants. Selective serotonin

reuptake inhibitors (SSRIs) regulate the serotonin system in the
brain. As you probably recall from chapter 1, serotonin is a neu-
rotransmitter involved in mood regulation. Common SSRIs
include paroxetine (brand name Paxil), fluoxetine (brand name
Prozac), and sertraline (brand name Zoloft). Their side effects can
include sexual dysfunction and digestive discomfort. SSRIs are
also helpful for treating symptoms of anxiety, which is commonly
experienced by individuals with bipolar disorder.
Tricyclic antidepressants, another type of antidepressants,
have been used to treat depression for over forty years. Tricyclic
antidepressants include imipramine (brand name Tofranil) and
clomipramine (brand name Anafranil). Their side effects can
include sedation, hypotension, dry mouth, and weight gain.
A third group of antidepressants, classified as monoamine oxi-
dase inhibitors (MAOIs), include isocarboxazid (brand name
Marplan) and phenelzine (brand name Nardil). MAOIs require a
special diet because the chemicals they contain interact with fer-
mented foods and beverages (for example, wine, beer, pickles, fer-
mented cheeses, and cured meats), so doctors typically choose to
prescribe other medications.
Lastly, bupropion (brand name Wellbutrin), venlafaxine
(brand name Effexor), and duloxetine (brand name Cymbalta)
are just as effective as other antidepressants at treating symptoms
of depression but are classified separately because they affect dif-
ferent chemicals in the brain. Side effects of these medications
can include headaches, nausea, sleep problems, agitation, and
sexual dysfunction.

52
 Medications

RISKS WITH STOPPING

MEDICATIONS
Thinking about stopping the use of medications, or even actually
stopping, is very common. It’s something most people go through
even when taking nonpsychiatric drugs, such as medication for
high blood pressure. Research has shown that seven out of every
ten people with bipolar disorder stop taking their medication at
some point, and nine out of every ten seriously consider discontin-
uing medication treatment (Colom and Vieta 2006). Unfortunately,
stopping medication often results in another mood episode, usually
within the next six months to one year, and also increases the risk
of suicide attempts (Tondo and Baldessarini 2000).
Stopping medications too quickly and without the guidance
of a doctor can also make you feel physically or emotionally sick.
If you abruptly stop taking SSRIs (antidepressants such as fluox-
etine and sertraline), you may experience flu-­like symptoms, sleep
disturbances, or digestive discomfort. This is called serotonin
withdrawal syndrome. This doesn’t occur because you’ve become
addicted to the medication; you can’t become addicted to antide-
pressants. Rather, this occurs because you suddenly stopped tak-
ing the medication, which affects the serotonin system in your
brain. Missing one day is unlikely to trigger this response, so don’t
panic if this happens.
If you want to stop taking your medication or are experienc-
ing troublesome side effects, talk with your doctor about other
options, such as gradually stopping a medication or switching to a
new one.

53
Bipolar Disorder: A Guide for the Newly Diagnosed

ELECTROCONVULSIVE THERAPY
For some individuals, medications and therapy may be less helpful
for treating their symptoms of bipolar disorder. In such cases, doc-
tors sometimes prescribe electroconvulsive therapy (ECT), a medi-
cal treatment that involves sending a low-­level electric current
through the brain for about one minute to induce a small seizure.
This is commonly conducted in a hospital under the care of phy-
sicians. ECT is usually tried when other treatments don’t work,
and it can be especially helpful for those experiencing severe
depression. Researchers don’t fully understand why this treatment
works, but it seems to help balance mood and decrease mood
symptoms. It is also used to treat acute mania and usually results
in rapid improvements without the side effects associated with
taking mood stabilizing medications. However, short-term mem-
ory loss may occur, which usually lasts only a few short weeks
after treatment. If you are interested in learning more about the
benefits and side effects of ECT, talk to your treatment provider.

QUESTIONS ABOUT MEDICATIONS

It’s likely that you still have questions or concerns about taking
medication. Having questions is a good thing; it means you’re
actively participating in decisions about your treatment. We’ll
answer some of the most common questions people have about
medications below. Since we probably won’t answer all of your
questions, we recommend that you work with your treatment
team to address any additional concerns you may have.

54
 Medications

Question: Are bipolar medications addictive?

Answer: Addiction is a common concern. However, there is no

risk of developing an addiction to the medications that doctors
prescribe to help balance mood, such as mood stabilizers, antisei-
zure medications, antipsychotic medications, and antidepres-
sants. These medications alter the chemicals in your brain in a
different way than addictive drugs, such as nicotine, alcohol, or
some nonprescribed drugs do. Some prescription medications,
such as particular antianxiety and sleep medications, do have the
potential to become addictive. However, doctors are trained to
prescribe these medications with caution. If you’re worried about
developing an addiction to a particular medication, you should
discuss your concerns with your doctor.

Question: How do I talk with my psychiatrist about changing

my medications?

Answer: As mentioned in chapter 2, it’s best to work with a doc-

tor you feel comfortable talking to about your concerns. It’s up to
you to advocate for yourself and make sure your concerns are
heard. Although your doctor is the expert regarding medications
and health issues, you’re the expert on your experiences. If you
feel the side effects of a medication are too much to handle, if you
don’t like the way a medication makes you feel, or if you want to
stop taking medication altogether, your doctor’s role is to help you
make safe and informed changes to your treatment plan. This can
happen only if you speak up and express your concerns. Discuss
any worries you may have, such as concerns about risks associated

55
Bipolar Disorder: A Guide for the Newly Diagnosed

with taking a medication for an extended period or during preg-

nancy. And if you have upcoming vacations or plans to move to
a new city or state, be sure to consult with your doctor about how
to make sure you continue to take medications consistently dur-
ing the transition.

Question: How can I be sure my medications are working?

Answer: We recommend tracking your mood, energy, and side

effects (this tracking is discussed in chapter 5) to gain a more
objective assessment of how well your treatment program is work-
ing. This will help you and your doctor notice changes in your
symptoms and document any unwanted side effects.

Question: If I’m feeling better, do I have to keep taking

medications?

Answer: It is human nature to think, I feel better, so I must be bet-

ter. However, medications are the best weapon against future
mood episodes. For medications to work and prevent relapse, you
should take them on a daily basis so there will be a consistent
level of medication in your system. This is what helps keep you
from experiencing symptoms. If you stop your medications when
you feel better and start taking them when symptoms return, it
may be too late to prevent a depressive or manic episode, as it can
take a couple weeks for the medications to start working again.
Research has shown that people who don’t take their medications
regularly are three times more likely to be hospitalized for a future
mood episode (Scott 2002).

56
 Medications

Question: How can I remember to take my medications?

Answer: Remembering to take medications every day is a chal-

lenge for most people. The good news is, there are several things
you can do to make it easier. For example, some medications are
available in a time-­release or extended-­release form (Seroquel
XR, Depakote ER). They are released slowly, throughout the day,
so you don’t have to remember to take pills as often. You can also
set up reminders on your phone or computer. Another option is to
create a routine to help you remember when to take your medica-
tions. For example, you could try taking your medications each
evening when you brush your teeth, or you could leave the pills
on your nightstand so you can take them as soon as you wake up.
If you take your medication at lunchtime, you can keep some pills
at your office so you don’t have to remember to take them with
you to work each day. You can also organize weekly pillboxes at
the beginning of each week or two so that you can easily tell if
you took your medications on a given day.

Question: How can I deal with side effects?

Answer: Side effects are most extreme during the first two weeks
of taking a medication, and many of them tend to go away as your
body gets used to the medication. If side effects continue, your
doctor may change the medication or prescribe additional medi-
cations to help treat the side effects. For example, you may take a
different medication to treat weight gain, which is a common side
effect of mood stabilizing medications. Although it is impossible
to eliminate all of the side effects you may experience, you can do

57
Bipolar Disorder: A Guide for the Newly Diagnosed

various things to help make them more bearable. For instance,

adding exercise to your routine or improving your diet can help
with weight gain or feelings of fatigue. You can eat sugar-­free hard
candy to decrease the discomfort of dry mouth. Some people feel
embarrassed by hand tremors that can be a side effect of some
medications; if that’s the case for you, you could use credit cards
rather than checks or money when in public so that people aren’t
as likely to see your unsteady hands. For side effects of sedation
and fatigue, you can take medications at night. If you feel like you
can’t tolerate a side effect, talk with your doctor to see if there are
other options available before discontinuing the medication.

SUMMARY
There are many different types of medications used to treat bipo-
lar disorder. The bad news is that this can be confusing initially.
The good news is that there are many different options, so if one
medication doesn’t work for you, there are others you can try. We
hope this chapter has given you the knowledge and resources to
become actively involved in decisions about medication and the
confidence to start an honest dialogue with your doctor if you
have any concerns about the medications prescribed for you.

58
 Chapter 4

c
c

Psychosocial
Treatments
That Work

As discussed in chapter 3, research shows that medication is the

most well-­supported and effective treatment for bipolar mania
and depression. However, medication is often only one part of the
overall treatment for bipolar disorder. And just as it’s very helpful
to know about current recommendations on medications, it’s also
important to be informed about other treatments, how they work,
and how helpful they are for treating symptoms.
In this chapter, we’ll discuss other treatments that, when com-
bined with medication, have been shown to increase the chances of
Bipolar Disorder: A Guide for the Newly Diagnosed

preventing future mood episodes and prolonging periods of well-

ness. These are commonly referred to as psychosocial treatments
because they involve a combination of psychological and social
interventions. You’ll also hear them referred to as talk therapies or
psychotherapies. Remember, different treatments and combinations
of treatments are more effective for different individuals. While we
can’t recommend which form of psychotherapy will work best for
you, we can explain what’s involved with each so you can work
with your treatment team to make an informed decision about
what treatment might be most helpful for you.

PROVEN PSYCHOSOCIAL
TREATMENTS
Research supports the effectiveness of several psychosocial treat-
ments for bipolar disorder, including psychoeducation, cognitive
behavioral therapy, family-­focused therapy, and interpersonal and
social rhythm therapy. All four of these treatments have been
found to decrease symptoms of depression, while psychoeduca-
tion seems to be equally effective for decreasing both mania and
depression symptoms. All four treatments decrease the chances
of hospitalization, and all of them also help people rebuild their
social world after a manic episode. However, it is important to
remember that medication is still the best and quickest treatment
for reducing symptoms of mania and preventing their return. Talk
therapies can be used as a supplement to medication.

60
 Psychosocial Treatments That Work

Psychoeducation
Psychoeducation involves increasing your knowledge about
bipolar disorder, its causes, and how clinicians diagnose and treat
it. You learn about the features of bipolar disorder, how to recog-
nize symptoms, how to identify triggers of mania and depression,
and how to minimize the chances of experiencing another mood
episode. Psychoeducation includes helping you develop strategies
to ensure you take your medication and engage in behaviors that
help you stay healthy, such as getting enough sleep and identify-
ing early warning signs of an oncoming mood episode. It also
teaches you to minimize the experiences that put you at risk for
relapse (for example, by reducing stress and substance use and
using effective problem-­solving strategies when necessary) and
helps you plan for what to do if you do become depressed or
manic. You may be thinking that many of these topics are
included in this book, and you’re right—­reading this book is a
component of psychoeducation!
There are three types of psychoeducation: individual, group,
and family, all of which involve working with a therapist. The first
two are designed to provide psychoeducation to those with bipo-
lar disorder. Individual psychoeducation can be incorporated into
one-­on-­one therapy between you and your therapist. Group psy-
choeducation involves learning about bipolar disorder together
with other people who also have the illness. The group approach
can provide you with additional support from people who under-
stand what it feels like to have similar experiences and can also
help decrease any stigma you might feel about having a diagnosis
of bipolar disorder.

61
Bipolar Disorder: A Guide for the Newly Diagnosed

When combined with medication, psychoeducation can help

decrease your chances of having a future episode of mania or
depression, reduce the amount of time you spend in manic or
hypomanic episodes, and make it less likely that you’ll be hospi-
talized (Colom and Vieta 2006). Psychoeducation is a component
of all of the other psychosocial interventions we discuss in this
chapter.
The third type of psychoeducation is for family members of
people with bipolar disorder. Family psychoeducation may be
offered to family members individually or to a group of family
members. Either way, your family members can work with a men-
tal health professional to learn about the disorder and how to
support you in staying well.

Cognitive Behavioral Therapy

Individual therapy can help you stay well and provide support
as you learn more about your diagnosis and your particular symp-
toms. Cognitive behavioral therapy (CBT) is the most carefully
studied form of individual therapy for depression and is also effec-
tive for treating both depression and mania in bipolar disorder.
CBT is a type of talk therapy that focuses on patterns of thoughts,
feelings, and behaviors and helping people identify the relation-
ship between those patterns and the symptoms they experience
(Beck 1964).
When you’re depressed, CBT helps you identify the negative
thinking that may be contributing to your mood and helps you
work on changing your thoughts and behaviors to improve your

62
 Psychosocial Treatments That Work

mood. Let’s walk through an example of what CBT looks like.

Let’s say that when you’re depressed you have little motivation to
go to work. You think to yourself, If I wasn’t so awful, I’d be able to
do my job like everyone else. This thought leads you to feel sad,
hopeless, and generally bad about yourself (feelings), so you call in
sick and isolate yourself from other people (behaviors). These
thoughts, feelings, and behaviors reinforce each other. For exam-
ple, staying home (behavior) reinforces your thought that you
don’t do your job well, and spending so much time alone (another
behavior) makes you feel lonely, so you end up feeling worse.

Cognitive Behavioral Therapy Model (adapted from Beck 1964)

Thoughts
“If I wasn’t so awful,
I would be able to do my
job like everyone else.”

Behaviors Feelings
Isolation Sadness
Calling in sick Hopelessness

Continuing with this example, in CBT, you would work with

your therapist to recognize your tendency to think in negative
ways and identify how your thoughts lead to feeling unproductive
and helpless. Your therapist would help you identify and change
these negative thoughts and set goals to get work done and

63
Bipolar Disorder: A Guide for the Newly Diagnosed

increase the amount of time you spend with others. Together,

these strategies could start to improve your mood and decrease
your negative thoughts and feelings.
Depending on your symptoms and goals, CBT can also
include coming up with strategies to target the overly positive
thinking that’s common in mania. CBT may help you learn
behavioral strategies to decrease the risk of mania, such as reduc-
ing social stimulation and exciting activities when your mood
begins to feel high. Other facets of CBT involve learning practical
skills to protect yourself from making risky financial or interper-
sonal decisions once your mood is high—for example, placing a
limit on your credit cards or even making them unavailable for a
couple of days. Some people we know actually freeze their credit
cards in a tray of water; by the time the cards have thawed out of
the ice, the urge to spend has usually passed. You may also learn
to minimize other consequences of feeling manic—for example,
by avoiding large crowds or interactions with new people on days
when your mood is high. While these kinds of strategies are
important for assisting you in understanding and changing manic
behaviors to stay healthy and minimize negative impacts of manic
episodes, CBT is most helpful for reducing the frequency and
duration of depressive episodes.
There is also some evidence that CBT is most beneficial for
people in the early stages of bipolar disorder. This is one reason
it’s helpful to educate yourself on treatment options as early as
possible (Scott 2001). Additionally, sometimes people use CBT to
address other types of difficulties beyond depression and mania,
such as managing anxiety, and this is an option you can discuss
with your treatment team.

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 Psychosocial Treatments That Work

Family-­Focused Therapy
Family-­focused therapy (FFT) is a type of treatment that
combines psychoeducation with family therapy. In FFT, individu-
als with bipolar disorder and their families work together to learn
about the features of bipolar disorder, how to recognize and
decrease symptoms, and healthy ways to support the person with
the diagnosis. FFT also focuses on how family relationships, con-
flicts, and the emotions family members express to each other
can either help or hinder the well-­being of the person with bipolar
disorder. In these ways, FFT helps families maximize strategies for
staying well.

Family-­Focused Therapy Model

Family Conflict Symptoms

For example, in FFT you and your family might work together
to improve your communication styles by practicing and improv-
ing skills for listening, expressing feelings, and requesting behav-
ior change. FFT is also designed to decrease harsh expressions of
negative emotions such as criticism or hostility.
When combined with medication, FFT is helpful for reduc-
ing depression symptoms and increasing the ability to take medi-
cations as prescribed (Miklowitz et al. 2003). FFT can be helpful

65
Bipolar Disorder: A Guide for the Newly Diagnosed

even if you participate in only a few sessions. Researchers have

found that as few as two FFT sessions help increase family mem-
bers’ positive communication, and that this helps improve mood
in the person with the diagnosis (Simoneau et al. 1999). Combined
with medication, improving the way your family functions appears
to be one way to decrease symptoms of bipolar disorder and pro-
long wellness.

Interpersonal and Social Rhythm Therapy

Another approach to staying healthy is to decrease behaviors
or experiences that may make symptoms more likely to occur.
Interpersonal and social rhythm therapy (IPSRT) focuses on
reducing risk factors that could contribute to relapse. For exam-
ple, there is strong evidence that sleep deprivation can trigger
manic symptoms (Colombo et al. 1999). There is also good evi-
dence that stress and interpersonal conflict can trigger depressive
symptoms for a person with bipolar disorder (Johnson 2005a). In
IPSRT, you learn strategies for reducing these risk factors.
Research shows that when IPSRT is combined with medication,
it is helpful for decreasing symptoms of depression and preventing
future depressive episodes (Miklowitz et al. 2003; Frank et al.
2005).
IPSRT is designed to address the disruption to circadian
rhythms that commonly occurs in bipolar disorder. Circadian
rhythms are the internal biological cycles that regulate many of

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 Psychosocial Treatments That Work

the body’s daily processes, such as sleeping and waking. IPSRT

includes strategies to help you recognize events that can disrupt
your schedule, such as traveling to another time zone, doing shift
work, or not having a regular daily routine. Stress and changes in
relationships can also disrupt schedules and sleep. IPSRT focuses
on helping you develop a regular routine for important activities
like sleeping, eating, taking your medications, and exercising, and
this can aid in preventing relapses. To that end, an IPSRT thera-
pist might work with you to record and improve your sleep habits
and daily routines.
A second set of skills in IPSRT involves identifying key stress-
ors and social difficulties and working to improve those areas of
your life. In IPSRT, you might choose one or two central sources
of stress and work with your therapist to come up with a game
plan for addressing them.

Interpersonal and Social Rhythm Therapy Model

.

Interpersonal
Problems
Or Symptoms
Disruption in Daily
Routines

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Bipolar Disorder: A Guide for the Newly Diagnosed

OTHER APPROACHES TO TREATING

BIPOLAR DISORDER
While the treatments we just reviewed are the most commonly
recommended—­ in combination with medication—­ there are
other strategies. However, these have less research supporting
their effectiveness in treating bipolar disorder. When deciding on
the right treatment plan, it’s important that you sort through your
options carefully and even critically, weighing the pros and cons
of each option with your treatment team.

Support Groups
It can be comforting to interact with other people who have
a diagnosis of bipolar disorder. No one knows more about this ill-
ness than others who have experienced the same ups and downs.
Joining a support group can help you connect with people who
have had similar experiences, enhance your ability to stay well in
times of stress, and give you the opportunity to both give and
receive support. Support groups provide a great outlet to share
symptoms, struggles, and accomplishments with a community of
people who understand your experiences.
Support groups are usually organized by treatment facilities
or consumer groups and are available in person and online for
both individuals and their families. Although support groups
offer the opportunity to meet new people and create new friend-
ships, they aren’t for everybody. Some people find that it can be
overwhelming to hear about other people’s difficulties with the

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 Psychosocial Treatments That Work

disorder. If you find that for any reason you aren’t comfortable in
a given group, you may want to try other support groups in your
area to find a group you feel comfortable with. The atmosphere,
level of positivity, and style of different support groups can vary
widely. Also, be aware that although confidentiality is expected,
it isn’t guaranteed in a support group, so you may want to be care-
ful about how much personal information you share. A great
resource for finding local and online support groups is the
Depression and Bipolar Support Alliance website (under the Find
Support link at www.dbsalliance.org).

Spirituality and Religion

While faith and prayer are comforting for people with a large
range of health problems, there is no evidence that they are as
effective for treating bipolar disorder as medications or the psy-
chosocial treatments we reviewed in this chapter. Spiritual prac-
tices may be a helpful addition to other treatments, but they are
not as effective by themselves.

Exercise
Regular exercise can help all people maintain a healthy life-
style. However, it is important for people with bipolar disorder to
regulate their exercise routines so they don’t get overenergized or
excessively goal-­driven, and so exercise doesn’t interfere with
sleep. The best way to incorporate exercise into your life is to

69
Bipolar Disorder: A Guide for the Newly Diagnosed

make sure you exercise for short periods on a regular schedule,

and that you do so fairly early in the day.

Diet and Vitamins

While there appears to be a lower rate of bipolar disorder in
countries with higher fish consumption (Noaghiul and Hibbeln
2003), there is no evidence that supplementing with omega-­3
fatty acids (which are abundant in seafood) has any impact on
symptoms or relapse. Furthermore, taking vitamins or other
nutritional supplements isn’t likely to be as beneficial if this isn’t
accompanied by other lifestyle changes, such as getting enough
sleep, eating healthful food, and exercising.

DECIDING WHICH TREATMENT IS

BEST FOR YOU
So now that you know more about effective treatments for bipolar
disorder, how do you decide which is best for you? Research com-
paring cognitive behavioral therapy, family-­focused therapy, and
interpersonal and social rhythm therapy found that, when com-
bined with medication, any of these therapies help speed recovery
from bipolar depression and prevent future episodes (Miklowitz et
al. 2007). All of these therapies appear to be equally effective
when used in combination with medication. Additionally, ther-
apy lasting several months helps more than psychoeducation last-
ing a few weeks.

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 Psychosocial Treatments That Work

There are a number of important characteristics that all of

the psychosocial treatments we’ve reviewed here have in com-
mon. First, research supports the effectiveness of all of these
interventions for treating bipolar disorder when combined with
medication. Second, each treatment includes education about the
disorder, either for those with bipolar disorder individually or as
part of a group, or for family members. Third, all of these treat-
ments help people identify, track, and prevent symptoms and
future episodes. Lastly, these interventions all assist people in cre-
ating and maintaining more regular routines and patterns of
behavior. Thus, psychosocial treatments can be very useful in
helping you learn more about bipolar disorder and providing tools
you can use to stay healthy.
When choosing which route to take, it’s important to think
carefully about which treatment is the best fit for you. If your
diagnosis is fairly new or you feel you don’t know very much about
bipolar disorder, you might want to start with a psychoeducation
program. Then, depending on what your goals are, you may prefer
one type of therapy to another. For instance, it may help to think
about whether you’re experiencing difficulty with negative think-
ing (in which case CBT might be best), family conflict (in which
case FFT might be best), or interpersonal problems or disruptions
in your daily routines (in which case IPSRT might be best). Also
consider which symptoms are most problematic for you—­
depression or mania. (If mania is more problematic for you, IPSRT
would probably be your last choice.) Be sure to discuss your
options and preferences with your treatment team so you can
work together to come up with the best plan to help you take care

71
Bipolar Disorder: A Guide for the Newly Diagnosed

of yourself. The summary below may help you think through

these factors when choosing a psychosocial treatment.

SUMMARY OF PSYCHOSOCIAL
TREATMENTS THAT WORK
Treatment: Psychoeducation
Who participates?
People with bipolar disorder (one-­on-­one or in a group) or
family members

Some knowledge and skills you’ll learn

• What bipolar disorder is and how it is diagnosed

• How to recognize symptoms of mania and depression

• Ways to track early warning signs

• What to do in case of an emergency

Most helpful for symptoms of…

Mania and depression

You may want to consider this if you…

Want to learn more about what bipolar disorder is and how
to recognize and respond to symptoms

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 Psychosocial Treatments That Work

Treatment: Cognitive Behavioral Therapy (CBT)

Who participates?
People with bipolar disorder

Some skills you’ll learn

• How to identify patterns in thinking, feeling, and

behaving
• Ways to identify and change negative thought patterns

• Ways to decrease overly positive thinking in mania

Most helpful for symptoms of…

Depression, and can also help with symptoms of mania

You may want to consider this if you…

Tend to have overly negative thinking or want to under-
stand how your thoughts, feelings, and behaviors are
connected

Treatment: Family-­Focused Therapy (FFT)

Who participates?
People with bipolar disorder and their family members

73
Bipolar Disorder: A Guide for the Newly Diagnosed

Some skills you’ll learn

• How to improve family communication styles

• How to identify and solve family conflicts

• Strategies to decrease expression of negative emotions

Most helpful for symptoms of…

Depression, and can also help with symptoms of mania

You may want to consider this if you…

Want to resolve family conflicts or work on communication
with family members

Treatment: Interpersonal and Social Rhythm

Therapy (IPSRT)
Who participates?
People with bipolar disorder

Some skills you will learn

• Ways to reduce stress

• How to ensure you take your medication regularly

• How to improve relationships with others

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 Psychosocial Treatments That Work

• Strategies to maintain regular daily routines, including

sleeping, waking, eating, and exercising

Most helpful for symptoms of…

Depression

You may want to consider this if you…

Have difficulty maintaining a regular schedule or have
interpersonal difficulties

WHAT TO EXPECT IN
PSYCHOTHERAPY
Once you decide which type of psychotherapy is the best fit for
you, you may wonder what the experience will be like. If you’ve
never been in therapy before, it can understandably be over-
whelming at first. Most therapies involve meeting with a therapist
once a week, but this varies depending on the severity of your
symptoms and how you’re doing at a particular time. Sessions
usually last about fifty minutes, but again, this may vary depend-
ing on your goals and level of distress. Most therapies are designed
to be short-­term, meaning that treatment will probably last twelve
to sixteen weeks.

75
Bipolar Disorder: A Guide for the Newly Diagnosed

Something important to remember about psychotherapy is

that you tend to get out of it what you put into it. The more you
open yourself up to the process and to working collaboratively
with your therapist, the more you will benefit from the tools and
strategies you learn. Just as importantly, if you aren’t comfortable
with the type of therapy you’re receiving or if you have questions
about your treatment, you should always discuss your concerns
with your therapist or other members of your treatment team. You
will benefit the most from psychosocial interventions when you
have strong and open communication with your care providers
about your progress, how you’re feeling, and, of course, any symp-
toms you’re experiencing.
Most people feel a bit intimidated about asking therapists
questions, particularly when meeting them for the first time. As
discussed in chapter 2, it’s reasonable to ask questions, including
how much experience therapists have with treating bipolar disor-
der and which of the treatments for bipolar disorder they feel
comfortable offering. That said, what’s most important is to find
someone you’ll feel comfortable talking with about difficult
experiences.
Some people simply feel uncomfortable about seeking ther-
apy. They worry that it’s a sign of weakness, or that somehow they
should be able to conquer mental health issues on their own.
However, mania and depression are very hard experiences to
come to terms with, and restoring your sense of confidence in
yourself after an episode can be a challenge. Having a therapist is
like having a coach who offers support in that process and helps
you rebuild parts of your life that might have been damaged by
symptoms. Therefore, it isn’t surprising that people who seek

76
 Psychosocial Treatments That Work

effective therapy for their bipolar symptoms tend to feel better

about their life and stay well for longer periods.

SUMMARY
There are several effective psychosocial treatments that can be
helpful for bipolar disorder. Choosing the treatment or treatments
that are best for you or your family may depend on which aspects
of your life you most want to improve. Another factor is whether
you would prefer to work with a therapist individually or in a
group setting. Work with your treatment team to decide which
options best fit your goals.

77
 Chapter 5

c
c

Learning to Notice
Early Warning
Signs and Triggers

Noticing changes in your mood or behaviors can help protect you

from future mood episodes. For example, you may notice that you
don’t want to spend time with family or friends or that you’re get-
ting into arguments with strangers for no reason. Events like
these may indicate that your mood is beginning to get too low or
too high. The earlier you notice these changes, the more time you
have to protect yourself from experiencing additional or more
intense symptoms in the future. In this chapter, we’ll review
changes in your emotions, behaviors, and thoughts that may
Bipolar Disorder: A Guide for the Newly Diagnosed

occur before mood episodes (warning signs), as well as life events

that may increase your risk for an episode (triggers). In the next
chapter, we’ll talk about strategies to implement when you notice
these early warning signs and triggers.

WARNING SIGNS
Before you become depressed, manic, or hypomanic, you may
experience behaviors, thoughts, or emotions that act as clues,
telling you that your mood is going up or down. We call these
warning signs.

Common warning signs of depression

• Lower self-­esteem

• Social isolation

• A drop in academic or job performance

• Problems with memory or attention

• Feeling fatigued

• Enjoying activities less

• Worrying more

• Talking less than usual

• Neglecting important activities

80
 Learning to Notice Early Warning Signs and Triggers

• Apathy or feeling indifferent

Common warning signs of mania or hypomania

• Sleeping less

• Feeling impatient

• Feeling irritable

• Having more energy

• Talking faster or more frequently than usual

• Driving faster

• Starting many new projects at once

• Feeling more confident

• Changing the way you dress

• Experiencing increased sexual feelings

These are just examples, and each person’s warning signs may
be different. Even for a given person, the warning signs may
change from one mood episode to the next. As you can see, warn-
ing signs can be symptoms of depression, mania, or hypomania.
As explained in chapter 1, you must experience a certain number
of symptoms for a certain amount of time for the term “mood
episode” to apply. However, symptoms that occur before an actual
episode of mania or depression may be warning signs that you are

81
Bipolar Disorder: A Guide for the Newly Diagnosed

moving toward relapse, and noticing these warning signs can help
you take action to stay well.
People often wonder how they can tell the difference between
normal changes in mood and warning signs. The basic difference
is that normal mood swings tend to disappear after a few hours.
An example would be getting into an argument with a friend and
feeling down for the afternoon, but feeling better and moving on
to thinking about other things by the end of the day. The warn-
ing signs of a mood episode, on the other hand, tend to get worse
over time. For example, after that argument with a friend, you
feel low for several days, start to isolate yourself from your friends,
and begin experiencing changes in your appetite and sleep.

TRIGGERS
Equally as important as identifying warning signs is thinking
about what causes those warning signs to occur. Sometimes
things that happen in your life, both good and bad, can influence
your mood. These are called triggers because they may result in
mood symptoms or an episode of mania or depression. Importantly,
triggers tend to come before warning signs. So if you can identify
your triggers, you can intervene even sooner, taking care of your-
self and implementing strategies to prevent mood symptoms from
arising or developing into another episode. Identifying triggers is
particularly important with mania and hypomania, because the
time it takes to go from having only a few symptoms to experienc-
ing a full-­on episode can be just a few hours or days, rather than

82
 Learning to Notice Early Warning Signs and Triggers

the days or weeks it may take with depression. As with warning

signs, each person can have different triggers.

The Links Between Triggers, Warning Signs, and Risks

Trigger Warning Signs Increased

(for example, (for example, feeling sad Risk for
losing your job) and hopeless and canceling Depression
plans with friends)

Identifying your triggers can help you ward off symptoms and
feel more in control of your illness. Here are some common trig-
gers people with bipolar disorder report. When reading this sec-
tion, think about whether these may be triggers for you and
whether you can identify any others.

Stress. Major life stressors and experiences, whether good or bad,

are often triggers for symptoms. Common triggers for depression
include losing friends or family members or losing a job. Common
triggers for mania include receiving a promotion or experiencing
a terrific social event, such as falling in love. Chronic stress,
meaning stress that lasts a long time, can lead to both physical
and psychological problems, including disruptions in sleep,
changes in regular routines, or changes in mood, all of which can
increase the risk of another mood episode.

Achieving goals. While negative life events can trigger depres-

sion, experiencing successes and having exciting new opportuni-
ties may lead to an increase in mania symptoms (Johnson et al.

83
Bipolar Disorder: A Guide for the Newly Diagnosed

2008). Although most people find it rewarding to reach their

goals, research suggests that individuals with bipolar disorder may
be more sensitive to rewarding experiences (Johnson 2005b). For
example, people with bipolar disorder tend to place a higher
importance on pursuing goals, even when they aren’t experienc-
ing a manic episode (Johnson, Eisner, and Carver 2009). This
can lead to an escalating cycle in which achieving a goal triggers
symptoms of mania, such as feeling overconfident, and then,
when manic, you feel more impulsive and able to achieve any-
thing you put your mind to. As a result, you may pursue several
large projects at the same time, regardless of whether you have
the resources to complete them. We don’t advocate abandoning
your goals; rather, we encourage you to be aware of changes in
your confidence level, pace yourself, and choose realistic steps
toward achieving your goals without taking too many risks.

Changes in sleep habits. Changes to your normal sleep schedule,

including getting significantly fewer hours of sleep than usual,
can trigger episodes of mania (Barbini et al. 1998). For example,
pulling all-­nighters or getting only a few hours of sleep for two
nights in a row may be enough to trigger a manic episode for some
individuals. In addition, sleep regulates dopamine receptors in
the brain, and as mentioned in chapter 1, dopamine is a neu-
rotransmitter that’s related to emotions and pleasure. Having
emotionally charged experiences just before bed, such as thinking
about exciting events, can also disrupt sleep for people with bipo-
lar disorder (Harvey, Talbot, and Gershon 2009).

Exercise. Although exercise can act as a natural antidepressant,

it also has stimulating properties that may trigger mania if it

84
 Learning to Notice Early Warning Signs and Triggers

interferes with your sleep or dominates your daily activities. We

recommend that you exercise regularly and schedule your work-
outs during the morning or early afternoon. Exercising late in the
day may keep you awake longer and interfere with your ability to
get a good night’s sleep on your regular schedule. It may also lead
to excessive goal-­driven behavior.

Drugs and alcohol. Many people with bipolar disorder find

themselves drawn toward using drugs to help regulate their moods
and sleep. Often, this ends up backfiring and people find it diffi-
cult to control their drug use. Generally, drugs that make you feel
more energetic or that interfere with your sleep carry a major risk
of triggering an episode of mania. For example, powerful stimu-
lants like cocaine or speed and some hallucinogens, such as LSD,
increase your energy level and decrease your need for sleep, which
can overwhelm your body’s ability to regulate your mood and
sleep. With substances that tend to have more calming effects,
such as barbiturates or alcohol, you run the risk of triggering
depression with repeated use. In addition, many nonprescription
drugs can interfere with prescription medications, which may
lead to unanticipated side effects. If you’re finding it hard to man-
age your use of any drugs, seek professional help so you can learn
alternative ways of coping. In addition, you should always discuss
any drug or alcohol use with your treatment team.

Caffeine. Caffeine is another substance that may disrupt your

daily routine and sleep schedule and trigger changes in your
energy level and mood. It’s best to limit your consumption of food
and drinks containing caffeine, including coffee, energy drinks,
and some multivitamins. Some individuals are more sensitive to

85
Bipolar Disorder: A Guide for the Newly Diagnosed

the effects of caffeine than others, and if you find you tend to
become very energized from caffeine, don’t underestimate the
impact of a late-­night soda, a piece of chocolate, or even a cup of
green tea.

THE IMPORTANCE OF BEING AWARE

OF SYMPTOMS
It’s important to notice triggers and warning signs as early as pos-
sible. The more intense your symptoms are or the more symptoms
you experience, the less able you are to recognize that you may
need help or take the necessary steps to get support. Having
insight into your symptoms is particularly important with mania
and hypomania. In mania, as you experience more symptoms,
your awareness of your symptoms decreases, so you’ll have more
trouble seeing that you’re becoming manic and that you need to
get help.
Sometimes people enjoy feeling hypomanic and want the
feeling to last longer. However, it’s important to recognize that
hypomania can be like skating on thin ice. Chances are, your
mood will continue to climb. The longer you wait to try to bal-
ance your mood, the harder it will be to recover from your symp-
toms. This may sound scary. However, by identifying triggers and
early warning signs, you give yourself the opportunity to inter-
vene on your own behalf before your insight decreases so much
that you’re unaware that you need support.

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 Learning to Notice Early Warning Signs and Triggers

IDENTIFYING WARNING SIGNS

AND TRIGGERS
In this section, we provide some strategies to help you identify
your warning signs and triggers by looking for patterns in your
moods and experiences. Keep in mind that this can be a chal-
lenging task, and it may take some time to get into the habit of
practicing these strategies. However, the more you learn about
yourself and your experiences with bipolar disorder, the easier it
will be to notice changes in your mood, thoughts, and behavior.
In chapter 6, we’ll talk about what to do once you recognize
warning signs or see that you’re experiencing triggers.

Make a List
Some people find it helpful to make a list of their warning
signs and triggers. There are many ways to create your list. One
way is to think about whether you tend to have certain symptoms
or experiences before an episode. To do so, it’s often easiest to
think about your most recent episode and work your way back-
ward. For example, you may recollect that before your most recent
depressive episode, you were really stressed at work. Or you might
look back at your most recent manic episode and realize that, at
the very outset, you started spending excessive amounts of money.
Noticing patterns in your routine can be another helpful way
to track when your mood is becoming too low or too high. Ask
yourself, What am I doing today? For example, when you’re feeling

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Bipolar Disorder: A Guide for the Newly Diagnosed

sad, you may notice that you have trouble completing your usual
tasks: The dishes are stacking up, your to-­do list only gets longer,
and you cancel plans with friends. Not having any plans for the
day could be a warning sign that you need to take care of yourself
by scheduling some small events that are rewarding or pleasant.
On the other hand, with mania you may find that every minute
of the day is filled. For example, you might feel too busy to take
lunch breaks because you have so many things you want to do.
Getting too busy or overly engaged with projects can be a warn-
ing sign of mania, and if you notice this happening, you can use
the insight to try to work on one goal at a time.
Here’s an example of a list of warning signs and triggers.

Sarah’s Warning Signs for Mania

1. Great mood, feeling on top of the world

2. Sleeping less than 6 hours a night

3. Spending more than $300 a week on things I don’t need and

can’t afford

4. Thinking people are frustrating and too slow

5. Others seeing me as moving too fast and being too enthusias-

tic about my projects

Sarah’s Triggers for Mania and Hypomania

1. Staying up late and not getting enough sleep

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 Learning to Notice Early Warning Signs and Triggers

2. Drinking caffeinated beverages

3. Completing a big project at work

Ask Others for Help

Another strategy for figuring out patterns in your history is to
enlist the help of close family members, trusted friends, and your
treatment team to see what changes they’ve noticed when you’ve
started to feel too high or too low in the past. For example, your
friends may help you see that you tend to become more talkative
when moving toward a manic episode because they’ve noticed
that they can’t get a word in edgewise during those times. They
may comment that this tends to happen when you are working
long hours. Or perhaps your family might help you see that you
enjoy your favorite activities less when you start to become
depressed, and that this tends to happen when you don’t see
friends on a regular basis. Getting others’ input can help you
make sure you don’t forget any important warning signs or trig-
gers when you make your list. In addition, it may be comforting to
talk with trusted friends and family members about what role
they might play in helping you stay well.

Use a Daily Mood Chart

One useful strategy for identifying mood patterns is to use a
daily mood chart to track changes in your mood day to day. There

89
Bipolar Disorder: A Guide for the Newly Diagnosed

are many free online tools you can use to do this. For example,
http://moodtracker.com has a helpful worksheet to record how
you feel each day. It allows you to graph when you’re feeling high
or low, how much sleep you’re getting, and any changes in your
medications. The Depression and Bipolar Support Alliance
(DBSA) has a website (www.facingus.org) featuring a mood
charting tool that allows you to record even more daily and
weekly details, such as changes in your lifestyle or health. It’s
called the Wellness Tracker and can be accessed through the
Tour or Resources links. A similar charting tool can be found at
www.healthyplace.com (under Tools); it’s called the Mood
Journal. Another site, www.moodscope.com, helps you track your
moods through a simple card game you play each day.
Mood tracking can help you identify your warning signs and
triggers. When tracking indicates that your mood is getting
higher or lower, you can make a list of what’s going on for you,
such as situations or times that have made you feel better or
worse. With time, you may be able to identify warning signs and
triggers that consistently occur for you before an episode, point-
ing out the kinds of occurrences you should pay particular atten-
tion to in the future. Mood charts are also a good way to
communicate your experiences or progress to your treatment
team.
The Depression and Bipolar Support Alliance Facing Us
website also has an online Wellness Plan tool that helps you com-
pile personalized lists of warning signs and triggers and a crisis
plan. If you prefer to use a book instead of an online tool, you may

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 Learning to Notice Early Warning Signs and Triggers

want to consider The Bipolar Workbook: Tools for Controlling Your

Mood Swings, by Monica Ramirez Basco, or some of the other
books listed in the Resources section at the back of the book.
In a typical mood chart, you’d list your prescribed medica-
tions and indicate whether you took them as scheduled. You can
also note whether your mood is high or low, how much sleep
you’ve gotten the night before, and whether you’re using any sub-
stances. In addition, it’s a good idea to list your daily activities and
make notes about anything else that seems to have a bearing on
your mood. Space doesn’t permit us to include a full mood chart
here; however, we’ve provided a streamlined version that you can
use if you’d like to create your own mood tracking chart. This is
just an example, and over time, you may find other ways to cus-
tomize your daily mood chart.

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Bipolar Disorder: A Guide for the Newly Diagnosed

Weekly Mood Chart

Dates:

Day of the Week 1 2 3 4 5 6 7

Med 1:

Med 2:

Med 3:

Severe

High Mood Moderate

Mild

Mild

Low Mood Moderate

Severe

Hours of Sleep

Anxiety (rate 0 to 10)

Irritability (rate 0 to 10)

Alcohol or drug use?

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 Learning to Notice Early Warning Signs and Triggers

Work on a Life Chart

Understanding patterns in your mood is a work in progress,
not something that can be done in one sitting. While it can help
to record your daily moods and behaviors, it’s also helpful to track
the history of your symptoms in earlier years. By looking for pat-
terns involved in your previous mood episodes, you can increase
your understanding of your mood. While similar to keeping a
mood chart on a day-­to-­day basis, this approach, known as life
charting, involves thinking about mood episodes in hindsight and
recording details of your experience over the years, such as the
different symptoms you’ve experienced, when they occurred, how
severe they were, how often they occurred, which treatments
were effective at treating them, and what potential triggering
events transpired before the onset of symptoms. This technique
can help you keep a thorough record of your mood history across
your life.
Because it involves thinking about multiple episodes of mood
disturbance and a longer history, life charting is best done in col-
laboration with your treatment team. It can help both you and
your treatment team notice patterns in your mood over time and
help guide decisions about your treatment. Bipolar Network News
(bipolarnews.org), an online clearinghouse for information on
mood disorders, has a thorough description of life charting for
both past and current events that is accessible through the Life
Charts link. As with mood charts, you can design your own sys-
tem for keeping track of your mood episodes and periods of well-
ness depending on what works best for you. Here’s an example of
what a completed life chart might look like.

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Bipolar Disorder: A Guide for the Newly Diagnosed

Aug 2004 March

to Oct 2005 to Oct 2006
2004 July 2005 to Feb 2007

Severe Mania

Moderate Mania

Mild Mania

Mild Depression
Moderate
Depression

Severe Depression

Started
school and
moved from Took leave Returned to school,
Life Events home from school stopped lithium

Medication Lithium Lithium Depakote

School/Job New school Semester off New coursework

SUMMARY
Detecting changes in your mood in a timely way is crucial to
avoiding an episode. Noticing small changes in your emotions,
behaviors, and thoughts can allow you to quickly take steps to

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 Learning to Notice Early Warning Signs and Triggers

intervene on your own behalf and stay healthy. The triggers that
lead to episodes and the point at which it’s important to take
action differ from person to person. The best thing to do when
you’re experiencing symptoms is to notify your treatment team so
you can work together to make a decision about the best steps to
help you stay well. In chapter 6, we’ll provide strategies for
responding to warning signs and triggers once you notice them,
for coping with changes in your mood and behavior, and for cre-
ating a plan in case your mood becomes more extreme.

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 Chapter 6

c
c

Strategies for
Responding to
Warning Signs
and Triggers

As discussed in chapter 5, noticing changes in your mood, behav-

ior, or thoughts as early as possible can help you stay well. These
changes, or warning signs, are reminders to take care of yourself
and get additional support. Sometimes it can be hard to know if
the warning signs you’re experiencing need to be treated, and if
so, how. When you begin to notice warning signs or simply aren’t
feeling like yourself, a good first step is to get in touch with your
Bipolar Disorder: A Guide for the Newly Diagnosed

treatment team so they can give you their opinion on whether it

would be helpful to increase your support or focus on coping
skills.
In this chapter, we’ll discuss what to do if you notice your mood
is getting too high or too low, including strategies to help you bal-
ance your mood and techniques for prolonging wellness. Research
has found that people with bipolar disorder are able to recognize
when they’re experiencing warning signs of depression and mania,
that they can use this information to implement strategies for bal-
ancing their mood, and that doing so benefits their well-­being
(Lam and Wong 1997). This chapter will help you do the same.

STRATEGIES FOR RESPONDING TO

WARNING SIGNS OF MANIA
In chapter 5, we discussed ways to identify symptoms of mania as
part of a strategy to help prevent relapse, but once you notice
them, what can you do? Thinking ahead and identifying strate-
gies you will use when you notice that you’re getting irritable or
your mood is getting high can help you get the support you need
and increase your chances of remaining well. There are three
main types of strategies: self-­calming, self-­protection, and manag-
ing medications and other treatments.

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 Strategies for Responding to Warning Signs and Triggers

Self-­Calming Strategies
Strategies to help you feel calm and relaxed can help balance
your mood when you start to feel hypomanic or manic. Here are
some things you can try:

• Increase the number of hours you sleep to a minimum

of ten. Before the development of current medications
for bipolar disorder, sleeping was actually one of the
main treatments for mania. In fact, sleeping for a long
time for three or four days in a row can be enough to
restore mood and prevent relapse. If you can’t fall
asleep, resting quietly without TV, radio, or other dis-
tractions in a quiet room can still be restorative.

• Limit the number of activities and tasks you’re doing.

Remember that avoiding relapse is more important
than a work obligation or social commitment. If you
have difficulty scaling back, try to prioritize your
activities as soon as you notice that your mood is get-
ting higher, then focus only on what is most
important.

• Spend no more than six hours a day being active,

and try to spend the rest of the day resting and relax-
ing, seeking as much tranquility as you can find and
limiting your outings.

• Don’t try to subdue increased energy with efforts to

exhaust yourself with exercise or more activity. The
more active you are, the more stimulated you’ll

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Bipolar Disorder: A Guide for the Newly Diagnosed

become and the more energetic you’ll feel. As men-

tioned in chapter 5, when you feel manic or hypo-
manic, exercise is recommended only if it is gentle and
controlled, doesn’t interfere with sleep, and doesn’t
become excessive or intensify your energetic state.

• Reduce stimulation. For example, avoid places or

situations that you find highly energizing, such as
shopping centers, crowded parties, or romantic situa-
tions. Instead, choose a relaxing environment—­
somewhere quiet, with low light and few people.

• Avoid food and beverages containing stimulants,

such as coffee, tea, soda, and energy drinks; multivi-
tamins and over-­the-­counter medications sometimes
contain caffeine too. Also avoid alcohol and stimu-
lating drugs. Even if you’re able to limit your alcohol
consumption, it’s best to not drink at all if you start
to notice symptoms.
• Engage in calming activities, such as taking a walk,
doing deep breathing or yoga, or meditating. Even
something like sitting in a rocking chair and listen-
ing to relaxing music or being around calm people
can help steady your mood.
• Have a go-­to list of a few small actions you can take
to slow yourself down, like sitting in the sun for ten
minutes or calling a friend who you find soothing.

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 Strategies for Responding to Warning Signs and Triggers

Self-­Protection Strategies
After a manic or hypomanic episode, people sometimes find
that they’ve done things that make their recovery more difficult,
such as spending more money than they have or making major
decisions without thinking them through. Here are some strate-
gies you can put into place ahead of time to make it easier to
prevent these kinds of outcomes if your warning signs or symp-
toms become more severe:

• If you notice symptoms of mania or any of your warn-

ing signs, limit your spending. You can ask your
credit card company to lower your credit limit or ask
a trusted friend to hold on to your credit cards—­
especially if you notice that you feel like going on a
shopping spree. As mentioned in chapter 4, some
people freeze their credit cards in ice to help them
postpone making purchases for at least twenty-­four
hours. This can give you time to think about your
decision before spending.

• Postpone making any big decisions until after you’ve

spoken with your treatment team or a supportive
friend or family member. For example, don’t start a
new business or a political venture while your mood
is high. Have a rule that you’ll sit on any major deci-
sion for twenty-­four hours to give yourself time to
weigh the pros and cons. If an opportunity is truly a
good fit for you, it’s likely that you can still pursue it
later, when you’re feeling calmer.

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Bipolar Disorder: A Guide for the Newly Diagnosed

• Don’t give yourself permission to feel high “a little

longer.” Remember, the higher you go, the harder
you’ll fall. The sooner you can reduce symptoms of
hypomania or mania, the less likely it is that these
symptoms will progress into a manic episode.

• Talk to someone you know well and trust to get some

perspective on your experience. Others may be able
to help you determine whether your behavior is out
of the ordinary.

• In general, try not to act impulsively or put yourself

in situations where you could endanger yourself.
Avoid new flirtations and romances and unsafe sex.
Stay away from conflicts and conflictual situations.
If you’re tempted to speed when your mood is high,
don’t drive. Avoid high-­ pressure social situations,
such as public speaking engagements.

Managing Medications and

Other Treatments
Don’t stop taking your medications when you experience
symptoms, particularly when you’re feeling energized and confi-
dent. As mentioned in chapter 3, it’s common for people to think
they don’t need their medications when they’re hypomanic or
manic. When you notice changes in your mood, it may be helpful
to consult with your psychiatrist to see if it would be appropriate

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 Strategies for Responding to Warning Signs and Triggers

to increase or change your medications. Sometimes an adjust-

ment to your medications can make a big difference in whether
your warning signs develop into a manic episode. Don’t adjust
your dosages or make any other medication changes without the
guidance of your doctor. If you’re receiving treatment from a ther-
apist, it may help to increase the number of times you meet for a
while or to move your appointment to an earlier day or time of
day. Some therapists may even offer a check-­in over the phone.

STRATEGIES FOR RESPONDING TO

WARNING SIGNS OF DEPRESSION
Just as with mania and hypomania, it’s good to think ahead and
plan some strategies for balancing your mood when you start feel-
ing low. Once you begin feeling depressed, it can be hard to moti-
vate yourself to take action, making it especially important to
identify these strategies in advance. We have four primary recom-
mendations here: doing things that usually make you feel good,
exercising, taking advantage of your social support system, and
challenging negative self-­talk.

Doing Things That Usually Make

You Feel Good
When you’re feeling low, it’s often hard to find the energy or
motivation to do the things you usually like to do. However,

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Bipolar Disorder: A Guide for the Newly Diagnosed

staying active and engaged with others can help boost your mood
and keep a low mood from getting worse. While it can be difficult
to find the energy to do daily tasks, people often find that they
feel better once they get moving. Think about the experiences
that usually make you feel good, particularly when you’re feeling
sad or low. Make a list of them that you keep handy, and add to
your list whenever new ideas come to you. Include a wide variety
of activities, from simple to more ambitious. Then, when you’re
feeling low, plan out your day, actually writing your schedule
down and being sure to include time for these pleasurable activi-
ties. If it seems hard to gather the energy and motivation to do
something major, do something small off your list, such as walk-
ing around the block, taking a hot bath, or calling a fun friend. If
holding a conversation with another person feels too taxing,
going to a café or the movies and simply being around other peo-
ple may be enough to help boost your mood. Don’t wait until you
feel motivated to start these activities. Accomplishing even the
smallest task or doing something that might help lift your mood
even a bit will help you begin to feel more motivated.

Exercising
As we mentioned in chapter 5, exercise acts a natural antide-
pressant (Dunn et al. 2005) and can be a good mood booster
when you’re feeling low. Getting a workout in, however small, can
lift your mood and help you feel more motivated to interact with
others or complete tasks. For example, you can take your dog for
a walk or do some light stretching. Planning to exercise with a

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 Strategies for Responding to Warning Signs and Triggers

friend may help increase your motivation when you feel tired or
want to isolate yourself.

Taking Advantage of Your Social

Support System
Social support is a key ingredient in staying happy and
healthy. Social isolation is a common warning sign of depression.
If you find that you want to avoid interacting with others, that
might serve as a gentle reminder that it’s an important time to do
the opposite and reach out. Getting some support can help you
feel more connected to others and less alone in dealing with your
problems. Talking to your therapist or a trusted friend or family
member or attending a support group meeting can help boost
your mood and help you make it through a low period. If leaving
the house feels like too much, you can call someone supportive or
invite a friend or family member to visit you. Problems can some-
times seem bigger than they are when you try to deal with them
on your own. Talking through a problem with someone who cares
about you can help reassure you and put your concerns into
perspective.

Challenging Negative Self-­Talk

When your mood is low, you’re likely to feel bad about your-
self or even feel hopeless. You may view yourself and the world in
a negative light or feel like you don’t have much control over your
life. It’s common to get into a cycle of feeling low, then not doing

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Bipolar Disorder: A Guide for the Newly Diagnosed

things you need or want to do because you feel tired or discour-

aged, and then feeling worse because you aren’t able to get things
done. If warning signs or symptoms of depression return, try not
to beat yourself up. Instead, think about ways to actively work on
feeling better and getting the support you need. Often, people
who are depressed are much harsher toward themselves than they
would be toward a friend, so listen to your self-­talk and consider
whether you’d be so critical of a friend who was struggling.
Remember that everyone experiences stress, and that occa-
sionally having a hard time dealing with things is completely nor-
mal. Try not to fall into the trap of thinking you’re back at square
one when you feel stressed or overwhelmed. Everyone differs in
terms of which situations are stressful for them, so we all have to
come up with our own strategies for handling stress when it comes
up. Try thinking about the resources you have for coping with a
particular situation or reflecting on what’s been helpful in the past.
Remind yourself that most people have days when life is harder to
handle. Setbacks are unfortunate, but they can help you learn
something new about how to avoid similar problems in the future.

THE IMPORTANCE OF SLEEP

Since changes in sleep are known to trigger mood episodes, it’s
particularly important to maintain a regular sleep schedule. Seven
to nine consecutive hours of sleep is the ideal for adults. Sleeping
five hours at night and then taking a two-­hour nap doesn’t add up
to seven hours of consecutive sleep. Also note that it’s important
to maintain your sleep schedule on the weekends. Sometimes you

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 Strategies for Responding to Warning Signs and Triggers

may stay up late for whatever reason. When this happens, try to
stick to your schedule. It’s better to wake up at your usual time
than to sleep late to try to catch up on sleep. Sleeping in will just
make it more difficult to fall asleep at your regular time the next
night, making it more likely that you’ll get stuck in this disrupted
pattern.
Because good sleep habits can go a long way toward helping
you stay well, we’ll give you a number of tips for helping you keep
a regular sleep schedule:

• Keep a sleep diary—­a log to help you observe pat-

terns in your sleep. This can also help you notice
when warning signs or symptoms of mania or depres-
sion are starting, allowing you to take action as soon
as possible. The National Sleep Foundation has a
handy sleep diary you can use (search for “National
Sleep Foundation sleep diary” in an Internet search
engine).

• Identify how many hours you’ll sleep, set a regular

bedtime and awakening time, and try to keep to that
schedule. Even if you feel like you can’t sleep for
seven to nine consecutive hours, give yourself all of
those hours in one solid block for sleep or relaxation
in a calm environment that helps quiet your mind.
It’s especially important to protect your routine dur-
ing weekends, vacations, or travel.

• When you feel depressed, don’t sleep or lie in bed any

longer than seven to nine hours. If this is an issue,

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Bipolar Disorder: A Guide for the Newly Diagnosed

you may find it helpful to schedule activities or

appointments in the morning so you have added
motivation to get up and get going.

• Limit daytime naps to thirty minutes, and take a nap

only if it won’t interfere with your nighttime sleep.

• Limit your caffeine intake. This doesn’t mean just

coffee; don’t underestimate the impact of a late-­night
caffeinated soda, chocolate dessert, or cup of tea.

• Avoid shift work and other activities that might dis-

rupt your sleep schedule, such as late-­night parties.

• Schedule in time to exercise—­but not right before

bedtime! Exercise can help you sleep more soundly.
The best bet is to exercise in the morning or early
afternoon.

Some people need extra support in managing their sleep rou-

tine. If you have trouble maintaining a consistent sleep schedule
or find it difficult to fall asleep and stay asleep, talk to your treat-
ment team about other methods for regulating your sleep.
Psychiatrists can prescribe medications that can help, such as
zaleplon (Sonata) or eszopiclone (Lunesta). These medications
are usually prescribed to be taken as needed, also referred to as
PRN, meaning you can take them on nights when falling asleep
is especially challenging. Health professionals who specialize in
treating sleep difficulties can help you learn additional skills for
dealing with insomnia and regulating your sleep routine. For
example, you might consider cognitive behavioral therapy for

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 Strategies for Responding to Warning Signs and Triggers

insomnia, a treatment that has been shown to have long-­term

benefits for people with insomnia (National Institutes of Health
2005). This type of therapy focuses on tracking your sleep pat-
terns, helping you establish a regular sleep schedule, reducing
inaccurate beliefs about sleep, and lowering anxiety related to
sleep difficulties (Harvey 2008).

DEVELOPING A PLAN FOR

MANAGING TRIGGERS
As discussed in chapter 5, triggers are things that happen in your
life that may make it more likely that your mood will become
imbalanced. Even positive events, like starting a new job or going
on an exciting vacation, can be triggers. This doesn’t mean you
should avoid taking part in life’s experiences and adventures, but
it does mean it’s worthwhile to identify your personal triggers.
This can go a long way toward helping you know when you need
to put extra effort into taking care of yourself.
Once you’ve identified your triggers, there are things you can
do to prevent them from leading to an increase in symptoms,
including some of the strategies we’ve discussed in this chapter.
The first step is to make sure you have support and resources
available to manage symptoms if they do occur. You should also
consult with your treatment team whenever you experience
changes in your life that may act as triggers, or ask trusted friends
and family members to help provide support when you’re going
through a challenging experience.

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Bipolar Disorder: A Guide for the Newly Diagnosed

For example, let’s say Michelle is up for a promotion at

work—­a positive but stressful situation that may be a potential
trigger. What can she do to make sure she remains in control?
She can discuss the promotion with her treatment team, watch
out for excessive focus on reaching her goals, and ask her family
to tell her if they notice any warning signs (for example, they
might say, “You seem really hyper and excited today. How’s your
sleep?”).
Or let’s say that Scott and his wife have a new baby on the
way, which will create a lot of new responsibilities for him. What
can he do to keep from feeling overwhelmed? He can increase his
social support by reaching out to friends and family members
ahead of time, and work with his treatment team to brainstorm
coping strategies for when the baby comes. He might need to
work out special arrangements so the baby doesn’t interfere with
getting solid sleep.
Anticipating potential events that may lead to changes in
your mood and developing plans for managing these situations as
they arise can help you feel more supported and decrease the
chances of relapse.

REMEMBERING TO IMPLEMENT
YOUR PLAN
We recommend developing a plan for responding to warning
signs and triggers when you’re feeling well. This will help you
cope more effectively if symptoms return. Once you’ve come up

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 Strategies for Responding to Warning Signs and Triggers

with a plan, set yourself up for success by creating reminders, such

as a wallet card or daily reminder card, so you can respond rapidly
when triggers or warning signs occur.

Wallet Card
Use a wallet card to record contact numbers for your treat-
ment team and the friends and family members who are most
supportive, as well as the first three steps you’ll take if your mood
gets too high or too low. This can be an invaluable resource if you
need immediate support. It can help you take control if symptoms
emerge and help remind you of how to best ask for extra support.
Like the list of warning signs discussed in chapter 5, the informa-
tion on your wallet card may change over time. Here is an exam-
ple of what the two sides of a wallet card might look like, along
with a blank version you can copy, fill out, and carry with you.

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Bipolar Disorder: A Guide for the Newly Diagnosed

THINGS TO DO IF
SYMPTOMS RETURN
Psychiatrist: Dr. Mark Jones
Phone: 510-­555-­5555
Address: 123 Anywhere St.,
Berkeley, CA
Therapist: Dr. Jane Smith
Phone: 510-­555-­1234
Address: 234 Fictitious Dr.,
Berkeley, CA

Support
1. Michael Thomas
Phone: 510-­555-­4321
Address: 2988 Unknown Ave.,
Berkeley, CA

2. Carlos Law
Phone: 510-­555-­6789
Address: 336 Ersatz St., El
Cerrito, CA

3. Mollie Washington
Phone: 510-­555-­1111
Address: 73 Pseudo St.,
Oakland, CA

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Strategies for Responding to Warning Signs and Triggers

THINGS TO DO IF
SYMPTOMS RETURN
When feeling high
1. Sit on big decisions for at least
24 hours!
2. Try to rest in a soothing
place. Turn down the lights.
3. Give my credit cards to my
brother.
What to say to friends/family:
I’m feeling a little excited today
and need to be in a calm
environment.
When feeling low
1. Stick with my normal
routine—­don’t keep sleeping.
2. Call a friend. Don’t isolate
myself!
3.  Go to my support group.
What to say to friends/family:
I’m feeling pretty down and need
your support in staying
connected.
If I can’t get in touch with a
support person or my symp-
toms continue, go to the
nearest emergency room.

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Bipolar Disorder: A Guide for the Newly Diagnosed

THINGS TO DO IF
SYMPTOMS RETURN
Psychiatrist:
Phone:
Address:

Therapist:
Phone:
Address:

Support
1.
Phone:
Address:

2.
Phone:
Address:

3.
Phone:
Address:

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Strategies for Responding to Warning Signs and Triggers

THINGS TO DO IF
SYMPTOMS RETURN
When feeling high
1.

2.

3.

What to say to friends/family:

When feeling low

1.

2.

3.

What to say to friends/family:

If I can’t get in touch with a

support person or my symp-
toms continue, go to the
nearest emergency room.

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Bipolar Disorder: A Guide for the Newly Diagnosed

Daily Reminder Card

It may help to set up a daily reminder to check your list of
warning signs and triggers. This will help you carefully keep track
of any symptoms so you can catch them as soon as they occur.
We’ve included some blank examples of daily reminder cards (one
for depression and one for mania or hypomania) so you can list
both your warning signs and triggers and your strategies for deal-
ing with them.
A daily reminder card is also a convenient place for you to
write out how you’ll communicate with friends and family mem-
bers during times when your mood is high or low. You may find it
helpful to put the card on your nightstand and just take a quick
glance at it at the same time each day to see how you’re doing.
You can always revise the list if you notice new warning signs or
triggers that are more meaningful or if you want to change the
order of the list. You can photocopy the blank form we provide, or
if you’d like more space, you can design something similar, in
which case you might want to put the triggers and warning signs
in one column and your planned coping strategies in another col-
umn alongside.

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 Strategies for Responding to Warning Signs and Triggers

Depression Daily Reminder Card

Depression trigger or warning sign 1: 
What I will do: 
Depression trigger or warning sign 2: 
What I will do: 
Depression trigger or warning sign 3: 
What I will do: 
Depression trigger or warning sign 4: 
What I will do: 
Depression trigger or warning sign 5: 
What I will do: 
Depression trigger or warning sign 6: 
What I will do: 
Depression trigger or warning sign 7: 
What I will do: 
Depression trigger or warning sign 8: 
What I will do: 

What I will say to friends/family: 

What friends/family will say to me: 

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Bipolar Disorder: A Guide for the Newly Diagnosed

Mania Daily Reminder Card

Mania trigger or warning sign 1: 
What I will do: 
Mania trigger or warning sign 2: 
What I will do: 
Mania trigger or warning sign 3: 
What I will do: 
Mania trigger or warning sign 4: 
What I will do: 
Mania trigger or warning sign 5: 
What I will do: 
Mania trigger or warning sign 6: 
What I will do: 
Mania trigger or warning sign 7: 
What I will do: 
Mania trigger or warning sign 8: 
What I will do: 

What I will say to friends/family: 

What friends/family will say to me: 

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 Strategies for Responding to Warning Signs and Triggers

SUMMARY
To stay well and prolong periods of wellness, you need to not only
recognize when your mood is getting high or low, but also think
through what you’ll do when you notice these warning signs. In
this chapter, we provided several strategies for responding to
warning signs of mania and depression. We also discussed the
importance of planning ahead and seeking increased support
when potential triggers arise. Think about which strategies you’ll
use when you start to feel too high and how you can boost your
mood and get moving if your mood starts getting low. These strat-
egies can be helpful at any point when you experience symptoms,
even when your symptoms have progressed and you’re in a manic
or depressive episode. Remember that involving your treatment
team and trusted family members and friends in your plan can
help you stay well by providing emotional support and helping you
track your symptoms.

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 Chapter 7

c
c

Telling Others
about Your Illness

Taking the time to think about and plan how you’ll talk about
your illness with people who aren’t mental health professionals
can make a big difference in the response and support you receive.
Although you are educated about your illness, others may, unfor-
tunately, be influenced by myths and biases about bipolar disor-
der. Sharing your situation with others for the first time can be a
delicate issue. In this chapter, we’ll provide tips on deciding whom
to tell about your diagnosis and help you develop a script for doing
so. We’ll also cover how to answer common questions that others
may have about your illness and how to take an active role in
obtaining help from others.
Bipolar Disorder: A Guide for the Newly Diagnosed

Deciding whom to share your diagnosis with is a complex and

personal decision. You may have many questions: What if I tell
someone and that person doesn’t understand? Should I tell a new
employer before or after I accept a job? What do I say to my chil-
dren? There are no clear rules about whom to tell, but thinking
through these questions ahead of time will allow you to weigh the
pros and cons and determine who needs to know and why. Your
treatment team can also be a helpful resource when making these
decisions.

DECIDING WHOM TO TELL

As with medical conditions, such as heart disease or asthma,
sharing details about your mental health isn’t always necessary.
You are in control of whom you tell and how much information
you share. Depending on how well you know someone, you may
feel more or less comfortable confiding in that person about your
illness. Here are some key considerations that can help you decide
who may be an appropriate and supportive person to talk to about
your illness.

What Are Their Attitudes toward

Mental Illness?
Assessing whether people are accepting and kind about men-
tal illness can be a good first step in deciding if you want to share
more about your experiences. Before telling people, you may want

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 Telling Others about Your Illness

to test the waters by bringing up the topic of mental illness with-

out personalizing it. For example, you could say something like
“Did you see that special on television about bipolar disorder?” or
“I read an interesting article on medications for treating bipolar
disorder.” People’s responses to such questions or comments may
give you clues about how open and knowledgeable they are about
mental illness. If they are warm and accepting, you may want to
share your diagnosis. If they are critical, make derogatory com-
ments, or seem apprehensive, you may not want to share your
diagnosis, or if it’s important to do so, you may want to try educat-
ing them about bipolar disorder before sharing your personal
experiences. Someone who isn’t open to hearing the truth about
bipolar disorder or who is unable to express empathy for people
affected by mental illness may not be a good source of support,
and therefore might not be a person to whom you want to disclose
your diagnosis.

What Will Sharing Your Diagnosis

Help You Achieve?
A good rule of thumb is to share your diagnosis with people
who will be supportive and understanding. If telling someone
about your illness will provide you with extra support, then it’s
probably a good idea to open up about your experiences. When
meeting new people, however, it generally isn’t a good idea to
share your diagnosis, since you haven’t established a close and
supportive relationship.

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Bipolar Disorder: A Guide for the Newly Diagnosed

If symptoms of your illness could affect your relationships

with certain people, it may be important to provide them with
information about your situation. For example, knowing about
your diagnosis may help your parents understand why you’ve
missed several family events or help your partner understand why
you’re more irritable and impatient at times.

Identifying the Pros and Cons of Sharing

If you decide that someone is accepting of mental illness and
will be supportive of you, the next step is to think about the pros
and cons of sharing aspects of your illness with that particular
person. Make a list of the benefits you anticipate and a list of the
potential costs so you can more objectively weigh them. Doing
this can help you decide whether or not to share this information
and increase your confidence if you decide to do so. Let’s take a
look at some examples of common benefits and concerns.

BENEFITS OF SHARING
The benefits of disclosing your illness will differ depending
on whom you’re telling and what you’re hoping to achieve. Here
are some examples, but make sure the benefits you list are appro-
priate to your unique experiences, the person you’re thinking of
telling, and your relationship.

• It will help explain some of my behaviors, such as why I

sometimes become isolated or have trouble following
through with plans.

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 Telling Others about Your Illness

• I can educate her about bipolar disorder so she’ll better

understand the illness and be less judgmental or afraid.

• She might not get as mad at me when I experience symp-

toms, like when I can’t motivate myself to get out of bed.

• She can help me identify some of my warning signs and

keep an eye out for triggers.

• I can lean on her for additional support.

• Being understood and accepted will feel good.

• I won’t feel like I’m hiding a piece of myself anymore.

POTENTIAL DOWNSIDES OF SHARING

It’s understandable that you may have worries or doubts about
how others will react when you share your diagnosis with them.
In the following list of downsides, we’ve included some common
concerns, but again, be sure you list your own worries and con-
cerns and how likely they are to actually occur. That can help
bring additional clarity to this important decision.

• He may not understand.

• He may think I’m crazy or be afraid of me.

• He could judge me and think it’s my fault that I have this

disorder.

• He may not want to be my friend anymore.

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• He may think I’m weak or fragile.

• He might think I’m unreliable or unpredictable.

• He may tell people who I don’t want to know about my

diagnosis.

WEIGHING THE PROS AND CONS

After constructing your lists of pros and cons, take time to
carefully weigh both sides. Pay particular attention to how many
items you’ve come up with for each list and how much impor-
tance or weight each item holds. Thinking critically about both
the benefits and the downsides of sharing your diagnosis with
someone will help ensure that you make an informed and bal-
anced decision.

DISCLOSURE SCRIPTS
Once you’ve made the decision to share your experiences of bipo-
lar disorder with someone, it’s important to think about the spe-
cific information you would like to share, how much detail to
provide, and what you’ll actually say. Creating a disclosure script
can make it easier for you to talk about this difficult topic, ensure
that you share only the necessary information, and help you if you
forget what you want to say. The goal is to help others understand
more about your illness in a way that will potentially increase
your support and reduce their misconceptions about

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bipolar disorder. You may need to use different disclosure scripts

with different people. When developing your disclosure script, it
can be helpful to keep a few guidelines in mind.

Focus on the biological causes. People often don’t realize that

bipolar disorder is a biological disorder, just like cancer or heart
disease. Focusing on the biological causes of the illness can help
others understand that you aren’t to blame for developing symp-
toms and that bipolar disorder is similar to other medical condi-
tions. However, remember from chapter 1 that although biological
factors can cause symptoms, symptoms aren’t permanent and
they can be treated. You’ll probably want to share this as well.

Highlight the medical symptoms. Many people can more easily

relate to the physiological symptoms of bipolar disorder, such as
having trouble falling asleep or increased fatigue, because they’ve
had similar experiences themselves. Focusing on these symptoms
can help demystify bipolar disorder because it highlights common
physiological experiences.

Use caution when discussing stigmatized symptoms. Some

people with bipolar disorder experience symptoms such as sui-
cidal thoughts, hallucinations, aggressive behavior, or hypersexu-
ality. These more severe symptoms can seem scary or strange to
people with limited knowledge about the disorder. Since these
symptoms are often misunderstood, we suggest you not mention
them when discussing your illness with someone for the first time.
In general, it’s best to discuss such symptoms only with your treat-
ment team and close family members and friends.

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Emphasize that you’re being treated. Bipolar disorder and its

effects on a person’s life and behavior are often misunderstood.
Although you know that there are helpful treatments that bal-
ance your mood and reduce symptoms, this may not be clear to
everyone. Sharing that you’re working closely with a treatment
team to manage your illness and that many people with bipolar
disorder can go years without symptoms tells others that your ill-
ness is under control and that you’re actively prolonging your
wellness. You might also stress that although bipolar disorder
influences your behavior, it doesn’t change who you are. Your ill-
ness is only one part of you, just like your hair color or family
background; it doesn’t define you.

Examples of Disclosure Scripts

Let’s start with an example of what not to say (adapted from
Colom and Vieta 2006): “I have a mental disorder that makes me
lose control of my emotions and behaviors. Sometimes I may act
really weird, and I have to go to the hospital until I’m normal
again. Once I tried to kill myself. I take pills that the doctors tell
me will help, but they make me feel like a zombie. My neighbor
says that these pills are addictive, so sometimes I stop taking them
until my symptoms come back.” This example goes against the
advice we shared above because it emphasizes a lack of control,
shares dramatic or severe symptoms, reinforces the myth that
bipolar medications are addictive, and doesn’t focus on the steps
you’re taking to stay well.

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Now let’s look at a couple of examples of more helpful and

positive disclosure scripts (adapted from Colom and Vieta 2006).
Here’s one approach you might use: “I have a medical illness
called bipolar disorder that affects various systems in my body
that help regulate mood. Sometimes I experience insomnia, anxi-
ety, and restlessness, and once I had to be hospitalized. Other
times, the disorder takes away all of my energy and makes me feel
extremely tired, and I experience severe physical discomfort.
Fortunately, I’m working with a treatment team and taking medi-
cations that help me a lot, though sometimes I may still experi-
ence symptoms or need extra support.”
Here’s another example of an effective approach: “I have a
psychological disorder that’s somewhat like many other medical
conditions you may be familiar with, such as diabetes or a thyroid
condition. It’s called bipolar disorder. It’s being treated and is
under control, but I want to tell you so that you won’t be surprised
if I show symptoms. For example, I might have a lot of energy and
have trouble sleeping, or I may feel really down and extremely
tired and unmotivated. I take care of myself. Just like people with
diabetes take insulin every day, I take medications, and some-
times I need adjustments to my medications, just like people who
take thyroid medications or insulin. I am still the same person
even though I have this diagnosis. It doesn’t define who I am.”
Compared to the first example, these two scripts are positive
ways to talk about your illness because they emphasize biology
and medicine, highlight that your symptoms are being treated
and you’re taking care of yourself, and communicate that your
illness is under control. They also help others understand that
one reason you’re sharing this information is so they won’t be

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surprised if you exhibit symptoms, and so they can be prepared to

offer support if necessary.

Developing Your Own Disclosure Script

Now that you’ve seen some examples of disclosure scripts,
take some time to think about how you’ll tell other people about
your illness. Remember that you may want to use different disclo-
sure scripts with different people. Even so, the same general
guidelines will apply in all cases. The point of a disclosure script
isn’t to hide aspects of your illness, but to provide clear informa-
tion about the less stigmatizing aspects of your symptoms when
telling others about your diagnosis for the first time.
After you initially share that you have bipolar disorder, tune
in to the other person’s reaction. Some people may have ques-
tions, while others may look at you blankly. Some will be support-
ive and understanding, while others may appear worried.
Continue to educate yourself about your illness so you can answer
questions, provide reassurance, and clarify any misconceptions
others may have. Assessing whether others will be warm, accept-
ing, and supportive is an ongoing process. Once you see a person’s
response to your initial disclosure, you can choose whether to
share more details about your illness.

CHALLENGES WITH DISCLOSURE

Below are some common questions people ask about sharing their
diagnosis with others. We’ve provided general information in

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response to each concern, but because everyone is unique and

every situation is different, it’s important to discuss your concerns
with your treatment team. That way you can get information rela-
tive to your situation and receive the support you need.

Question: What if people judge me or don’t understand?

Answer: It’s common to have worries and concerns about what
others will think of you once you disclose your illness. Although
you are knowledgeable about the causes and best treatments for
bipolar disorder, not everyone will be as informed. Sharing your
knowledge is the best defense against judgment. Also know that
there are some great resources to help people understand more.
At the end of the book you’ll find a Resources section that
includes books designed for family and friends and autobiogra-
phies of people with bipolar disorder. Talking to your treatment
team or a person you trust can also help you work through these
concerns and help you cope if people are judgmental or
unsupportive.

Question: Should I wait until I see symptoms before I tell

others?
Answer: As discussed in chapter 5, there is always a risk with
waiting until you notice symptoms to make decisions, get help, or
start treatment. The more symptoms you experience, the less
insight you may have that you need support. We recommend tell-
ing others about your diagnosis when you aren’t currently experi-
encing symptoms. This makes it more likely that they’ll be able to
provide support if your symptoms return.

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Bipolar Disorder: A Guide for the Newly Diagnosed

Question: Should I tell my children about bipolar disorder?

Answer: Telling children depends on their age. Explaining the
details of any complicated medical condition can be confusing to
children. There are children’s books that help to explain bipolar
disorder and address common concerns for a younger child (see
the Resources section at the end of this book). If you decide your
child is mature enough to learn more about your illness, you can
develop a script, focusing on the medical or physical symptoms
you experience. Then maintain an open and supportive dialogue
so you can address any questions or concerns that come up.
Because there’s a genetic component to bipolar disorder, educat-
ing your children about your illness can also help them notice
whether they experience symptoms and motivate them to learn
skills for managing their moods. You may want to come up with a
disclosure script to use with children with the advice and support
of your treatment team. Some children may fear that they will
develop the disorder; it is important for them to hear that most
children who have a parent with bipolar disorder will not develop
the disorder themselves.

Question: Should I tell people I’m dating or have just met?

Answer: Just because you have an illness doesn’t mean it’s the
most important thing about you or that you need to share this
information as soon as possible. Use the tips we provided earlier
to test the waters and determine whether new people in your life
are understanding and accepting about mental illness. Because
bipolar disorder is a chronic illness, someone who isn’t open to
learning about it probably won’t turn out to be a good fit for a
long-­term relationship. You’ll know when the timing feels right. If

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 Telling Others about Your Illness

you find yourself hiding or lying about your symptoms, it’s proba-
bly time to make a decision about whether to share your diagnosis
and how close you’d like the relationship to be.

Question: Should I tell my employer?

Answer: When deciding whether to tell your employer about

your diagnosis, ask yourself, Would I disclose my illness if it were
some other medical condition, such as migraines or diabetes? If not, it
may not be necessary to disclose that you have bipolar disorder. If
your symptoms affect your ability to fulfill your work require-
ments, however, you may want to talk to your employer to learn
more about potential accommodations (for example, flexibility in
your schedule and deadlines). If you’re looking for a new job, you
are not required by law to disclose your illness. However, we do
recommend gathering information about aspects of the job that
could trigger a future mood episode, such as shift work, stressful
deadlines, or extended workdays. This may help you decide if it’s
in your best interest to pursue the position.

Question: What are my rights in the workplace?

Answer: The Americans with Disability Act (ADA) protects all
people with physical or psychological disabilities against discrimi-
nation. Discrimination in the workplace includes denying people
employment opportunities or promotions or not offering reason-
able accommodations. However, in order to be protected under
the ADA, you must disclose your illness to your employer. To
learn more, visit the U.S. Equal Employment Opportunity
Commission (eeoc.gov).

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Bipolar Disorder: A Guide for the Newly Diagnosed

BEING OPEN TO EXTRA SUPPORT

Having conversations with others about the roles they’ll play in
your wellness helps you remain in control of when and how you
receive support and also puts systems for receiving support in
place before they’re needed. It’s human nature to feel hesitant to
ask for help when times are tough. It’s natural to think, I’ve been
through this before; I can get through it again on my own. While it’s
great to have confidence in your abilities, the fact is, it’s usually a
lot easier to cope when you have the support of others.
There may also be times when you don’t realize your symp-
toms have returned. At those times, it’s helpful to have trusted
friends, family members, or mental health professionals share
their observations. Sometimes it can be difficult to hear what
they have to say, especially if you don’t believe your symptoms
have returned. Talking to those you look to for support before you
experience symptoms will help them learn more about how they
can help, what to look for, and how to approach the topic so you’ll
be more willing to listen.

Developing a Support Agreement

Support agreements allow you to take an active role in the
support you receive from others by detailing when you’d like sup-
port, how you’d like others to help, and what you’d like them to
say to you when they notice warning signs. This can be especially
useful if you go through times when you are not as aware of your
symptoms or during times when you need some extra support.

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 Telling Others about Your Illness

Each support agreement will probably be different, depending on

the person and your relationship. And although many people find
this approach useful, it doesn’t work for everyone; it depends on
how comfortable you are with involving friends or family mem-
bers in your treatment plan.
In all cases, be very specific. Include warning signs that the
other person may notice that can serve as a signal that this is a
time when you would like help. Also explain precisely how the
person can help you best. Do you need a listening ear? Do you
want advice? Do you want the other person to help you make
decisions? Also think about the least threatening way the person
can approach you during these times. What would you like to
hear when the person notices warning signs?
The goal isn’t to feel like your every move is being scruti-
nized, but to have a safety net so that others can be a voice of
reason and support if you become less aware of your mood or
behaviors or less able to use strategies to help balance your mood.
Remember, the sooner you notice warning signs, the earlier you
can act on your plans for coping and maintain wellness.

Example of a Support Agreement

Here’s an example of a support agreement. We’ve also
included a blank form you can use for writing support agreements.
However, due to space constraints you may want to simply use the
example as a model for your own form. Either way, identify some-
one you can count on for support, then work together to develop
a support agreement.

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Bipolar Disorder: A Guide for the Newly Diagnosed

MARIA’S SUPPORT AGREEMENT

Who: Husband
When I would like help: When you notice that I charge more than
four hundred dollars on nonessential items in one week, sleep less than
five hours a night, or quickly jump to conclusions and start
arguments.
How you can help me: Be patient if I start an argument, help me
think through my purchases before I buy them, and, most importantly,
help me keep my appointments with my therapist and psychiatrist.
What I would like to hear: It would be helpful if you could say
something like “I’m noticing some of the warning signs we talked
about, and I want you to know I’m here to help if you need me.”

MY SUPPORT AGREEMENT
Who:

When I would like help:

How you can help me:

What I would like to hear:

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 Telling Others about Your Illness

SUMMARY
Sharing information about your illness and symptoms can be a
complicated endeavor. To help ensure that you receive the sup-
port and understanding you deserve, take the time to make care-
ful decisions about whom to tell and how much detail to share.
Think through the pros and cons of disclosing your diagnosis to a
particular person to help you make a decision that feels right to
you. If you decide to share your diagnosis, develop a disclosure
script for the conversation. Sharing your diagnosis with trusted
friends and family members will be beneficial, as it’s often easier
to cope with symptoms when you have the encouragement and
understanding of others. Also remember that your treatment
team can be a great source of support both when you’re experi-
encing symptoms and when you’re well.

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c
c

Staying Well and

Staying Hopeful

Once people are diagnosed with bipolar disorder, the focus on

symptoms, mood management, and wellness tends to overshadow
some of the good that comes with the diagnosis. One key benefit
is that it opens the door to setting wellness goals for managing
your illness and improving your general well-­being. We begin our
last chapter with some examples of wellness goals to get you
started. We’ll also briefly discuss some of the positive traits asso-
ciated with bipolar disorder, including creativity, ambitiousness,
and zest for life. We hope to leave you with a sense of hope,
empowerment, and encouragement that will help you play an
active role in shaping how this illness impacts your life.
Bipolar Disorder: A Guide for the Newly Diagnosed

SETTING WELLNESS GOALS

Receiving a diagnosis of bipolar disorder may feel devastating at
first. However, it is actually the first step on your road to health.
Now you can set wellness goals and decide which strategies and
skills you’ll need to use to reach them. Setting goals that are both
realistic and meaningful can help you stay motivated during times
when you’re feeling down or recovering from an episode of mania
or depression. Prioritizing your wellness goals and tracking your
progress will help you stay conscious of the positive steps you’re
taking to stay healthy. Here are some examples of possible well-
ness goals.

Preventing relapse. Because bipolar disorder can be a chronic

illness, one important goal is to prevent future episodes of mania
or depression. While you may not be able to completely eliminate
symptoms of the disorder, you can manage your symptoms and
extend periods of wellness by using the strategies in this book.

Managing your medications. Becoming more informed about

which medications work best for you, making it a priority to take
your medications regularly, and talking to a professional before
making changes or discontinuing your medication are important
wellness goals that can maximize periods of balanced mood.

Feeling more in control. Educating yourself by using self-­help

resources like those mentioned in this book and listed in the
Resources section can help empower you to manage your mood,
work collaboratively with others to stay healthy, and feel more in

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 Staying Well and Staying Hopeful

control of your well-­being. Staying involved in decisions about

your care and having a plan in place for when symptoms arise can
help you take responsibility for your wellness and increase your
self-­confidence that you can manage your triggers, notice warn-
ing signs, and cope with the inevitable difficulties in life.

Focusing on self-­care. As you now know, tracking your symp-

toms, building social support, managing stress, establishing daily
routines, getting enough sleep, exercising regularly (but not exces-
sively!), and making time for relaxation are all helpful strategies
for maintaining wellness. Additional self-­care approaches include
participating in the activities you enjoy, eating a healthful diet,
connecting with supportive people, and making sure you stay
centered. Working on these wellness goals will ensure that you’re
making your health and happiness a priority.

THE POSITIVE SIDE OF

BIPOLAR DISORDER
The media often portrays people with bipolar disorder as being
out of control or constantly experiencing symptoms. While this
may be true for some individuals, many people with bipolar disor-
der have full and satisfying lives (Coryell et al. 1998). Even though
many people struggle with this illness, about 25 percent of people
with bipolar disorder report that their work and social lives are
good or better, with as many as 15 percent describing their profes-
sional and personal abilities as “excellent” (Gitlin et al. 1995;

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Bipolar Disorder: A Guide for the Newly Diagnosed

Hammen, Gitlin, and Altshuler 2000). Furthermore, when more

than three thousand people with bipolar disorder were asked if
they would press a button that would eliminate the disorder,
about half said no, indicating that this illness has some positive
aspects and that people with this diagnosis can live fulfilling lives
(Wilson 2006).
Indeed, there is evidence that some people with bipolar dis-
order have exceptional qualities. Among the many notable people
believed to have or have had the disorder are artists Vincent van
Gogh, Edvard Munch, and Jackson Pollock; musicians Robert
Schumann, Brian Wilson, and Sergei Rachmaninoff; actors
Richard Dreyfuss, Carrie Fisher, Patty Duke, and Vivien Leigh;
and authors Charles Dickens, Ernest Hemingway, Edgar Allen
Poe, Virginia Woolf, William Faulkner, and F. Scott Fitzgerald.
Other public figures who have talked about their experiences
with bipolar disorder include Representative Patrick Kennedy
and media personality Jane Pauley. More recently, celebrities such
as Catherine Zeta-­Jones and Russell Brand have disclosed that
they were diagnosed with bipolar disorder, increasing public
awareness and understanding of this illness. When times get
tough, it can help to remember that you are not alone in experi-
encing symptoms and that people with bipolar disorder can have
successful careers and lead fulfilling lives.
Researchers have found that people diagnosed with bipolar
disorder exhibit a number of strengths (see Johnson et al. 2012 for
a more thorough review), including higher creativity, higher life-
time ambition, and more motivation to pursue goals. Moreover,
people diagnosed with bipolar disorder report a number of

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 Staying Well and Staying Hopeful

positive experiences associated with changes in their moods, such

as increased sensitivity and alertness, higher productivity, being
more comfortable and outgoing in social situations, increased
sexual enjoyment, and heightened creativity (Jamison et al.
1980). In fact, people with bipolar disorder are more likely to pur-
sue creative occupations than others are (Tremblay, Grosskopf,
and Yang 2010). The reasons why creativity is more common
among people with bipolar disorder aren’t fully understood, but
for many, this is one of the silver linings of the disorder.
Bipolar disorder is also related to the drive for success, and
those with the disorder tend to have higher ambition and confi-
dence about accomplishing difficult goals, particularly when
experiencing positive moods (Johnson 2005b). Perhaps the genes
for this disorder are in some way tied to the biological underpin-
nings of accomplishment. For instance, family members of people
with bipolar disorder tend to experience high levels of success in
both creative and career pursuits (Johnson 2005b).
Gaining control over manic symptoms may help these posi-
tive tendencies shine through. There is evidence that the milder
mania symptoms are, the greater the degree of accomplishment
in creative and other endeavors. And for those who do go through
manic episodes, quelling the most severe symptoms can help
them achieve more creative and professional success. To state it
more bluntly, symptoms of mania such as anger, hypersexuality,
and poor judgment may inhibit creativity and productivity.
Therefore, building a plan for wellness may provide the additional
benefit of helping you meet your career goals and be more
creative.

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Bipolar Disorder: A Guide for the Newly Diagnosed

MAINTAINING PERSPECTIVE AND

SELF-­ACCEPTANCE
Remember that having a diagnosis of bipolar disorder does not
define you. You are a person with bipolar disorder, not a bipolar
person. While having this condition requires that you monitor
your moods and receive lifetime treatment, you can still live a
rich and fulfilling life. Each step you take toward extending peri-
ods of wellness will increase your self-­awareness, help you recog-
nize your strengths, and allow you to learn from your
challenges.
There may be times during a manic or depressive episode
when you think or act in ways that aren’t consistent with your
personal goals or values. It can be easy to feel bad about yourself
in the aftermath. Having self-­compassion as you pick up the
pieces and get back on track can be as important as any of the
other strategies discussed in this book. Being willing to forgive
yourself and learning to use challenges and barriers as opportuni-
ties for growth are important steps on the path to wellness.

CLOSING THOUGHTS
We believe the key to staying healthy is learning as much as pos-
sible about bipolar disorder and strategies you can use to prolong
periods of balanced mood. You may recall that this type of learn-
ing is called psychoeducation, and in a sense, reading this book

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 Staying Well and Staying Hopeful

was like taking a mini psychoeducation course. We wrote this

book with the goal of helping you learn more about your illness
and empowering you to maximize your periods of wellness. We
congratulate you on finishing it! You have taken a meaningful
step toward building a plan for wellness.
You now know how doctors diagnose bipolar disorder, how to
identify symptoms of depression and mania, and how to find pro-
fessional help and choose the services and treatment team that
are best for you. You’re familiar with the types of medications
commonly prescribed to treat bipolar disorder and the psychoso-
cial treatments that can help you stay well. You have learned how
to identify your personal triggers and warning signs and why
doing so is important. You’ve learned strategies for responding to
or managing triggers and warning signs so you can minimize
symptoms when they occur. You’ve spent some time thinking
about factors that may influence whether you disclose your illness
to others and how you might talk with them about your illness.
Finally, you’ve considered some of the benefits of receiving a diag-
nosis and some of the positive aspects of the illness. Armed with
all of this information, you have tools for helping ensure your
well-­being and good reason to feel hopeful about the future.
We hope this book continues to serve as a useful resource
when you’re looking for information about what it means to have
bipolar disorder, strategies to manage your symptoms, or ideas on
how to extend periods of wellness. Although we have just summed
up the contents of this book in a few sentences, you’ve gained a
great deal of understanding, along with many helpful strategies

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Bipolar Disorder: A Guide for the Newly Diagnosed

for staying well, by reading these eight brief chapters. You are now
knowledgeable about bipolar disorder and, of course, an expert in
your own experience. We wish you the best, and we thank you for
allowing us to be part of your journey toward wellness.

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Resources

SELF-­HELP BOOKS
Basco, M. R., The Bipolar Workbook: Tools for Controlling Your
Mood Swings
Burns, D. M., Feeling Good: The New Mood Therapy
Fast, J., and J. Preston, Loving Someone with Bipolar Disorder
Jones, S., P. Hayward, and D. Lam, Coping with Bipolar Disorder:
A CBT-­Informed Guide to Living with Manic Depression
Last, C. G., When Someone You Love Is Bipolar: Help and Support
for You and Your Partner
Bipolar Disorder: A Guide for the Newly Diagnosed

Miklowitz, D., The Bipolar Survival Guide

Otto, M., and A. Henin, Living with Bipolar Disorder
Otto, M., N. Reilly-­Harrington, R. O. Knauz, A. Henin, J. N.
Kogan, and G. S. Sachs, Managing Bipolar Disorder:
A Cognitive Behavioral Treatment Program Workbook
Paterson, R., Your Depression Map: Find the Source of Your
Depression and Chart Your Recovery.
Phelps, J. R., Why Am I Still Depressed? Recognizing and Managing
the Ups and Downs of Bipolar II and Soft Bipolar Disorder
Torrey, E. F., and M. B. Knable, Surviving Manic-­Depression:
A Manual on Bipolar Disorder for Patients, Families, and
Providers

AUTOBIOGRAPHIES AND
NONFICTION ACCOUNTS
Gibbons, K., Sights Unseen
Solomon, A., The Noonday Demon: An Atlas of Depression
Styron, W., Darkness Visible: A Memoir of Madness
Jamison, K. R., An Unquiet Mind: A Memoir of Moods and Madness
Jamison, K. R., Night Falls Fast: Understanding Suicide
Jamison, K. R., Touched with Fire: Manic-­Depressive Illness and the
Artistic Temperament

148
 Resources

CHILDREN’S BOOKS
Chan, P. D., Why is Mommy Sad? A Child’s Guide to Parental
Depression
Holloway, A., The Bipolar Bear Family: When a Parent Has Bipolar
Disorder

PUBLISHERS AND MAGAZINES

New Harbinger Publications: newharbinger.com (books on
depression, bipolar disorder, anxiety, and more)
bp Magazine: bphope.com (“hope and harmony for people with
bipolar”)
Esperanza Magazine: www.hopetocope.com (“hope to cope with
anxiety and depression”)

INFORMATION ON TREATMENTS,
MEDICATIONS, AND REFERRALS
American Psychological Association: locator.apa.org
Association for Behavioral and Cognitive Therapies: abct.org
Depression and Bipolar Support Alliance: findapro.dbsapages.org
National Network of Depression Centers: www.nndc.org
/centers-of-excellence

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Bipolar Disorder: A Guide for the Newly Diagnosed

ORGANIZATIONS AND GENERAL

INFORMATION
Brain and Behavior Research Foundation: bbrfoundation.org
Depression and Bipolar Support Alliance: www.dbsalliance.org
Facing Us: www.facingus.org (various wellness tools and resources)
International Foundation for Research and Education on
Depression: ifred.org
National Alliance on Mental Illness: nami.org (consumer and
family support groups)
National Institute of Mental Health: www.nimh.nih.gov/health
/publications/bipolar-­disorder/complete-index.shtml
The Sean Costello Memorial Fund for Bipolar Disorder Research:
www.seancostellofund.org
Substance Abuse and Mental Health Services Administration:
www.samhsa.gov
U.S. Equal Employment Opportunity Commission: eeoc.gov

ONLINE TOOLS
Finance management: www.hellowallet.com
Life charting: bipolarnews.org/?page_id=175

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 Resources

Mood Tracking
https://moodtracker.com
www.moodscope.com
www.facingus.org/tour/tracker
Mood, sleep, and exercise tracking: www.medhelp.org
Sleep diary: type “National Sleep Foundation sleep diary” into an
Internet search engine
Wellness planning: www.facingus.org/tour/plan

Personal Testimonials
www.victoriamaxwell.com
www.youtube.com/user/DBSAlliance

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References

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160
Janelle M. Caponigro, MA, is a doctoral student in clinical sci-
ence at the University of California, Berkeley, specializing in the
social and emotional functioning of individuals with bipolar dis-
order and schizophrenia. She helped design and lead a sixteen-
week bipolar psychoeducation group.

Erica H. Lee, MA, is a doctoral student in clinical science at the

University of California, Berkeley, specializing in the sociocul-
tural and contextual mechanisms underlying child and adoles-
cent development and family functioning. She helped design and
lead a sixteen-week bipolar psychoeducation group.

Sheri L. Johnson, PhD, is professor of psychology at the

University of California, Berkeley. Her work has focused on bipo-
lar disorder, specifically, the processes that trigger manic relapse
and how these can be more effectively treated. She has published
over 130 articles and book chapters and has coauthored or coed-
ited numerous books.

Ann M. Kring, PhD, is professor of psychology at the University

of California, Berkeley. She has taught graduate and undergradu-
ate courses in severe mental illness since 1991. She has published
over eighty articles and book chapters, as well as five books.
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