Mood in bipolar disorder
Moods are temporary states of mind or feeling that lasts for hours or days. Moods don’t always have a discernible cause – you can simply feel a certain way for no specific reason. Moods are different from emotions. Emotions usually have a specific cause (i.e. “I feel excited about…”) and are usually briefer (seconds or minutes) and more intense than moods1. An emotion can lead to a change of mood (i.e., “My sister’s graduation was today and I felt so proud that I was uplifted for the rest of the day.”). When you have bipolar disorder, at their worst, extreme mood states can lead to hospitalization, problems with employers and loved ones, and sometimes even run-ins with the police. During recovery, less extreme mood states can also affect your quality of life.
The extreme mood states that can cause problems in bipolar disorder are:
Low mood and motivation, feeling flat or sad. Can be associated with changes in sleep, energy and concentration, and often feelings of worthlessness or guilt. It can be accompanied by unrealistic beliefs and perceptions in severe cases. A depressive mood state lasts at least two weeks and is so severe that it significantly disrupts your ability to function.
Elevated or irritable mood and hyperactivity. It can be associated with increased self-esteem, racing thoughts, distractibility, decreased need for sleep and engaging in risky activities such as those involving money or sex. Unrealistic beliefs and distorted perceptions can also occur. A manic mood state lasts at least one week and is so severe that it affects normal functioning.
Staying well with bipolar disorder involves continuously adjusting your mood with small lifestyle changes, as well as watching for your triggers and early signs that you might be entering a mood episode. Many people do well when they try and stay in a ‘happy medium’ – able to feel the normal highs and lows of life, but without too much stress and anxiety, and without sliding into an extreme mood state.
Understandably, people with bipolar disorder often worry about the difference between normal changes in mood and a mood change that might signal a problem. A good way to know the difference is to see if you can change your mood. If you’re feeling flat, see if you feel a bit better by doing something you would usually enjoy (e.g., treat yourself to your favourite TV show). If your mood lifts, that’s a positive sign. If your mood stays flat or low, then you might need to get some more help. Similarly, if you’re feeling particularly happy and excited, see if you can moderate the mood by taking a few minutes away from stimulation (e.g., sit down and read quietly). If you remain high and can’t concentrate, your mood might need some attention.
Even when not experiencing periods of depression and hypomania or mania, people with bipolar disorder often have problems with low mood (i.e., sadness) and anxiety2,3. People with bipolar disorder can benefit from the same strategies and behaviours that help anybody else stay happy and calm. Many of these are discussed elsewhere in the Bipolar Wellness Centre, where we discuss other aspects of quality of life that strongly impact mood (e.g., the domains of Sleep, Physical Health, Relationships, etc.). Here, we’ll focus on strategies that can help lift a lowered mood, decrease anxiety and stress, and we will share some tips for what to do if you feel like you may be moving into a mood episode.
How you can take action
People who manage their bipolar disorder well tell us that there are certain, specific strategies you can take to manage mood symptoms. Some of the simplest, most central strategies to enact are those that help to calm oneself and cope with stress. Many people with bipolar disorder find that it’s important to have a technique for relaxing, and to use it every day4. There is a big difference between an activity that tends to be relaxing (e.g., perhaps you find cooking or watching TV relaxing), and an activity that you deliberately do solely for the purpose of relaxation: an ‘active relaxation’ strategy. Such ‘active relaxation’ strategies might include meditation, yoga or mindfulness-based practices. If you don’t have an active relaxation strategy, it’s worthwhile to look into one.
Other stress management strategies include becoming aware of triggers for distress, developing the interpersonal skills of assertion (e.g., speaking up for yourself and others, disagreeing respectfully or saying ‘no’ without feeling guilty5), and becoming better at problem solving life’s difficulties. If you’re not used to these ways of dealing with stress and anxiety, it can help to be shown them in a course or with a counselor or therapist. Some examples identified by people with bipolar disorder and healthcare providers for calming are4:
- Allow time for relaxing activities
- Spending time in a quiet place
- Avoid scheduling too many social events
- Do not take on too many projects at one time
- Get organized
- Do not expect perfection
- Set realistic expectations
- Take care of basic needs first
These kinds of strategies are useful to have in place all the time to support your wellbeing, not just when you are concerned about a worsening mood. By improving your ability to cope with life’s challenges, you can reduce the risk of future depressive or hypomanic/manic episode. However, even if you regularly use these kinds of techniques, it’s important to have plans to monitor and respond to changes that might indicate a more serious mood episode.
There are three key steps to minimising mood episodes
Some people find the experience of monitoring mood can bring up difficult thoughts about your identity as someone living with a chronic mental health condition7. In some cases, people can also find that paying a lot of attention to their mood can increase rumination about depressive symptoms8. If this happens to you, it might be useful to process these experiences with a therapist and explore coping strategies that allow you to monitor your mood without triggering unpleasant emotions or thoughts. For example, our Identity page offers some tips on sustaining a healthy, well rounded, and positive sense of self. Qualitative research on people’s experiences with using the CREST.BD QoL Tool showed that monitoring quality of life alongside mood can help draw your attention to positive things in your life9.
Secondly, watch for your triggers. There is growing evidence that life stress can cause severe mood changes in bipolar disorder10. You can work out what these are by looking over your life and noting the sorts of events that tend to unsettle you. There are also certain triggers that seem to be important for many people with bipolar disorder11, and it can help to be cautious if any of the following are going on:
- Changes of season: A proportion of people with bipolar disorder are at increased risk of depression in the darker months and of hypomania or mania in the spring or summer.
- Changes in sleep: Decreased sleep may the risk for hypomania or mania, and increased need for sleep can be a sign of depression.
- Changes at work: Both negative and positive events at work can be triggers for unsettling your mood.
- Relationship stress: Conflict and fights in a relationship are stressful for everyone, and can increase risk for mood episodes.
- Pregnancy and childbirth: The biological, behavioural and social changes with pregnancy and childbirth are a major risk factor for triggering mood episodes in mothers who live with bipolar disorder. And although most research is in mothers, there could be increased risk for partners as well12,13.
- Grief and loss: Grief, divorce, losing a job, or permanent loss of health or security challenge anyone’s coping resources; however, there is a difference between the normal process of adjusting to a loss and the development of a new episode of depression, hypomania or mania.
- Drugs and alcohol: As fully described in the Substance Misuse section, substance use can cause mood symptoms and mood symptoms can cause substance use.
Third, respond early if you are entering a mood episode. Research has shown that there are some signs that are commonly reported in the early stages of extreme mood shifts11,14. Early signs that someone might be becoming depressed include low energy, feeling tired, difficulty concentrating, intrusive negative thoughts (unwanted thoughts that keep coming back), wanting to be alone, feeling irritable, sleeping too much or too little, feeling sad or wanting to cry, feeling flat, feeling anxious and feeling guilty. Early signs that someone might be becoming hypomanic or manic include feeling emotionally high, ideas flowing too fast, senses seeming sharper, colours seeming brighter, feeling especially creative, feeling irritable, increased interest in sex, difficulties falling asleep, feeling self-important and making lots of plans.
Monitoring mood, watching for triggers, and responding early can markedly increase your resilience and ability to cope with and prevent mood episodes. Your mood isn’t who you are, it’s just your mood at this point in time15. People who can recognise the early signs of mood episodes, and who respond in a timely and helpful or positive way, have a better course of bipolar disorder. Here are additional strategies to try:
Typical strategies for avoiding or stopping progression into elevated moods include decreasing stimulation of all kinds, slowing down behaviours and plans, decreasing the hunt for rewards, and decreasing emotionality and how you express your emotions.
Questioning your thinking before you act can help with elevated moods (i.e., mania and hypomania). People who are hypomanic or manic can behave in ways that are unusual, dramatic, or ostentatious16,17,18. If you are feeling very excited or elevated, it can be useful to question your thinking. For example, you could ask questions like:
- Is this what I would normally wear in this situation?
- How will others react to what I am about to say/wear/do?
- What harm is there in stepping back and fitting in with others today?
In elevated mood states, people can feel under pressure to make quick decisions19. This is called impulsivity, and can appear in different areas of your life. You can see more tips about managing impulsivity in specific life areas (e.g., finances, sex life, relationships) by visiting those Bipolar Wellness Centre pages. At highly impulsive times you might think: “If it feels good now, do it”, “I’ve got to act now”, “I’m sick of being controlled”, “I should never pass up an opportunity”. At moments like these you may want to take the action strategy of turning inwards for 30 minutes before acting, to list the pros and cons of the action you are considering. You could also make a list of negative outcomes of past impulsive actions, or check in with a trusted friend/family member about the likelihood of a plan succeeding. It also helps to question thoughts like these with questions like:
- Why not take a bit more time to think about my course of action?
- Have there ever been negative consequences of my impulsivity before?
Impulsivity can include acting on frustrated or irritable emotions in inappropriate ways. In such cases, it is important to remove yourself from the situation, use a calming technique or distraction to help you cool down, or harness that energy in a different way (e.g., exercise). Anger can be an adaptive feeling that alerts us to when things in our life are unfair, our boundaries have been violated, or something is preventing us from reaching goals. However, when hypomanic or manic, impulsivity can make it difficult to respond to those situations in a healthy way, and you may find life stressors trigger anger more quickly. Many people find it helpful to identify their early warning signs of anger (for example, feeling hot, tense, and sweaty, raising your voice or pacing) so that they can take preventative action before becoming overwhelmed.
How you think and act can influence whether a mild depressed mood turns into a severe episode of depression11. When people are feeling down, they tend to think in certain ways that can make them feel even worse, but knowing about these thought processes in themselves can be helpful, and is the first step to countering these thoughts. Strategies to keep structure in life and to stay engaged with supporters also help.
Here are a few types of thoughts you might have when depressed, and how to counteract them:
All or nothing thinking
All or nothing thinking, or perfectionism, refers to thinking about things at their extremes. Things are either ‘good’/perfect or ‘bad’/inadequate – there are no grey areas with this type of thinking. For example, “If I don’t get that job I applied for it means I am hopeless and no one will ever employ me”. “If I get frustrated with my children, it means I am a bad parent.” If you have these thoughts, know that there is evidence that counters them – and look for it.
Catastrophizing or fortune-telling
Catastrophizing or fortune-telling involves jumping to a negative conclusion. These thoughts can have their own momentum, and can “snowball” – that is, imagined negative impacts can grow quickly until they feel out of control. Not surprisingly, these types of thoughts are linked to feelings of anxiety and depression20,21,22. For example, “My partner was short with me this morning, so he must be upset with me… maybe he doesn’t even love me anymore.” To counter snowballing negative thoughts like this, ask yourself about other things that might have influenced this situation.
- “How do I really know this?”
- “My partner has an important meeting today, which is probably why they seem distracted.”
Mind reading is the belief that you know what other people are thinking. This type of thinking can be associated with feelings of anxiety, particularly in social situations. For example, “They must think I am really stupid for saying that.” If thoughts like this arise, ask yourself:
- “Where is the evidence for thinking this?”
- “How can I know what they are thinking?”
- “What else could they be thinking?”
- “I have no idea what they were thinking, maybe they were thinking ‘when’s lunch?’”
Overgeneralizing is a type of thinking when you believe that something bad will always occur, based on a previous unpleasant experience. These thoughts state that things will be like this ‘always’. For example, “I didn’t do well in high school, so I will not do well in this training course now”. Try to ground your thoughts to the specifics – this point in time, right now. Question these thoughts by asking yourself:
- ”How can I know this will be so?”
- “High school was 10 years ago, but this is a course I have chosen and am interested in – that is a big difference.”
Have a plan for episodes
Finally, have a plan for if the mood episode gets serious. There is research showing the importance of having a well thought out written-down plan for mood emergencies24,25.
Plan what you will do and say, whom you will communicate with, what you will ask family and friends to do for you, and any other contingency plans you feel are necessary for your life specifically. For example, you may ask your partner to take away your credit card if you’re feeling manic, your friend to drop in if you stop returning her calls, or your sister to provide emergency childcare. It is necessary to check with the people in your plan to make sure they are willing to play these roles, and in some cases you will need to explicitly authorize these people to take control of the areas you need their help; for example, most schools require a signature or consent from you in the case that you are authorizing an extra person to pick up your child. Lastly, you may want to give friends or family permission to let you know when you’re becoming unwell (and perhaps tell them how you would like to hear this information).
- Ekman, P., & Davidson, R.J. (1994). The nature of emotion: Fundamental questions. Series in affective science. Oxford University Press, NY, NY, p. 496.
- Savitz, J., van der Merwe, L., & Ramesar, R. (2008). Dysthymic and anxiety-related personality traits in bipolar spectrum illness. Journal of Affective Disorders, 109: 305-311.
- Judd, L.L., Akiskal, H.S., Schettler, P.J., Endicott, J., Maser, J., Solomon, D.A., Leon, A.C., Rice, J.A., & Keller, M.B. (2002). The long-term natural history of the weekly symptomatic status of bipolar I disorder. Archives of General Psychiatry, 59: 530-537.
- Suto, M., Murray, G., Hale, S., Amari, E., & Michalak, E.E. (2010). What works for people with bipolar disorder? Tips from the experts. Journal of Affective Disorders,124: 76-84.
- Nemours Centre for Children’s Health Media. “Assertiveness”. TeensHealth. December 8, 2014. http://teenshealth.org/teen/your_mind/friends/assertive.html
- Nicholas, J., Larsen, M. E., Proudfoot, J., & Christensen, H. (2015). Mobile Apps for Bipolar Disorder: A Systematic Review of Features and Content Quality. Journal of Medical Internet Research, 17(8), e198. https://doi.org/10.2196/jmir.4581
- van Bendegem, M. A., van den Heuvel, S. C. G. H., Kramer, L. J., & Goossens, P. J. J. (2014). Attitudes of patients with bipolar disorder toward the Life Chart Methodology: A phenomenological study. Journal of the American Psychiatric Nurses Association, 20(6), 376–385. https://doi.org/10.1177/1078390314558420
- Faurholt-Jepsen, M., Frost, M., Ritz, C., Christensen, E. M., Jacoby, A. S., Mikkelsen, R. L., . . . Kessing, L. V. (2015). Daily electronic self-monitoring in bipolar disorder using smartphones – the MONARCA I trial: a randomized, placebo-controlled, single-blind, parallel group trial. Psychol Med, 45(13), 2691-2704.
- Morton, E., Hole, R., Murray, G., Buzwell, S., & Michalak, E. (2019). Experiences of a Web-Based Quality of Life Self-Monitoring Tool for Individuals With Bipolar Disorder: A Qualitative Exploration. JMIR Mental Health, 6(12), e16121. https://doi.org/10.2196/16121
- Gilman, S.E., Ni, M.Y., Dunn, E.C., Breslau, J., McLaughlin, K.A., Smoller, J.W., & Perlis, R.H. (2015). Contributions of the social environment to first-onset and recurrent mania. Molecular Psychiatry, 20(3): 329-336.
- Lam, D.H., Jones, S.H., & Hayward, P. (2010). Cognitive therapy for bipolar disorder: A therapist’s guide to concepts, methods and practice (2nd ed.) Wiley-Blackwell, West Sussex, UK.
- Diflorio, A., & Jones, I. (2010). Is sex important? Gender differences in bipolar disorder. International Review of Psychiatry, 22: 437-452.
- Tsuchiya, K.J., Byrne, M., & Mortensen, P.B. (2003). Risk factors in relation to an emergence of bipolar disorder: A systematic review. Bipolar Disorders, 5: 231-242.
- Zeschel, E., Correll, C.U., Haussleiter, I.S., Kruger-Ozgurdal, S., Leopold, K., Pfennig, A., Bechdolf, A., Bauer, M., & Juckel, G. (2013). The bipolar disorder prodrome revisited: Is there a symptomatic pattern? Journal of Affective Disorders, 151: 551-560.
- Mansell, W., Morrison, A.P., Reid, G., Lowens, I., & Tai, S. (2007). The interpretation of, and responses to, changes in internal states: An integrative cognitive model of mood swings and bipolar disorders. Behavioural and Cognitive Psychotherapy, 35: 515-539.
- Lam, D., Wong, G., & Sham, P. (2001). Prodromes, coping strategies and course of illness in bipolar affective disorder–a naturalistic study. Psychological Medicine, 31: 1397-1402.
- Lam, D.H., Watkins, E.R., Hayward, P., Bright, J., Wright, K., Kerr, N., Parr-Davis, G., & Sham, P. (2003). A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: Outcome of the first year. Archives of General Psychiatry, 60: 145-152.
- Akiskal, H.S. (2005). Searching for behavioral indicators of bipolar II in patients presenting with major depressive episodes: The “red sign,” the “rule of three” and other biographic signs of temperamental extravagance, activation and hypomania. Journal of Affective Disorders, 84: 279-290.
- Mason, L., O’Sullivan, N., Blackburn, M., Bentall, R., & El-Deredy, W. (2012). I want it now! Neural correlates of hypersensitivity to immediate reward in hypomania. Biological Psychiatry, 71: 530-537.
- Hoyer, J., Gloster, A.T., & Herzberg, P.Y. (2009). Is worry different from rumination? Yes, it is more predictive of psychopathology! Psycho-Social Medicine, 6: Doc 06.
- McLaughlin, K.A., Borkovec, T.D., & Sibrava, N.J. (2007). The effects of worry and rumination on affect states and cognitive activity. Behavior Therapy, 38: 23-38.
- Roelofs, J., Huibers, M., Peeters, F., Arntz, A., & van Os, J. (2008). Rumination and worrying as possible mediators in the relation between neuroticism and symptoms of depression and anxiety in clinically depressed individuals. Behaviour Research and Therapy, 46: 1283-1289.
- Centre for Clinical Interventions (CCI). “Resources”. Centre for Clinical Interventions: Psychotherapy, Research, Training. December 8, 2014. http://www.cci.health.wa.gov.au/resources/infopax.cfm?Info_ID=38
- Yook, K., Kim, K.H., Suh, S.Y., & Lee, K.S. (2010). Intolerance of uncertainty, worry, and rumination in major depressive disorder and generalized anxiety disorder. Journal of Anxiety Disorders, 24: 623-628.
- Cook, J.A., Copeland, M.E., Hamilton, M.M., Jonikas, J.A., Razzano, L.A., Floyd, C.B., Hudson, W.B., Macfarlane, R.T., & Grey, D.D. (2009). Initial outcomes of a mental illness self-management program based on wellness recovery action planning. Psychiatric Services, 60: 246-249.