Relapses in bipolar disorder: signs and guidelines

It is crucial that we begin with some fundamental, non-negotiable principles. No one "is bipolar." To state something like that is to stigmatize oneself and therefore discriminate against oneself. A health problem does not define a person; it is not the essence of that person . It is a circumstance, "an accident," as Aristotle postulated. We ourselves must be the first to fight against stigma and discrimination. Words matter a great deal, especially in this context. To say, "we are bipolar," is the first step in identifying our identity with a medical condition. We could say, "I have a mental health problem," or "I have bipolar disorder," for example. But we will never be an illness!

That said, in my opinion, it's primarily about getting to know yourself well, with the help of the therapeutic team and reliable information. Having an excellent relationship with your therapeutic team is essential. If communication isn't good, or you don't have time to explain what's happening to you or ask all your questions, consider changing your approach. You have the right to do so. The focus should be on recovery . This generally means: "Living as well as possible, with or without symptoms." It's not just a medical issue; it's about developing strategies to have a purpose, to give meaning to your life (beyond simply feeling well). It's about having reasons to get up every day, recognizing that there are many facets of our lives that we need to develop and fulfill: financial independence, housing, education, rights, rewarding activities, and so on. And what I consider fundamental: a social network, emotional support, and shared interests.

Mutual support groups in the field of mental health

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I highly recommend connecting with others who have been through the same thing. I'm referring to peers. Mutual support groups , associations, and informal support networks are a very powerful tool. It's possible to have a good life. Take good care of your sleep, manage your stress, lead a healthy lifestyle, and don't stop exercising. In this last sense, walking is part of your recovery process. And above all, try not to pathologize any discomfort you experience. All human beings go through difficult times. Stigma and discrimination, as you know, are an added burden that can be worse than the health problem itself. Fight against it, first and foremost, by not seeing yourself as "sick"; we are people, citizens, not patients.

Helping someone who is suffering always means being there for them. Empathy means trying to put yourself in their shoes. Putting yourself in the place of someone going through a crisis can be difficult if you haven't experienced it yourself, but thanks to experience and having information from those close to them, you can help.

The work should begin earlier, when everything is going well. This involves establishing a bond of respect and understanding between both parties, learning as much as possible about bipolar disorder, and, above all, asking the person how they would like to be supported during potential crises. This preliminary work is the most important.

If the person trusts you, you can suggest, for example, accompanying them to their appointment with their therapist and first asking them the series of questions they have to ask the therapeutic team.

Going through a mixed episode is very uncomfortable. Often, there's irritability and low mood at the same time. It seems to me that if you live with the person experiencing it, just like with any other kind of crisis, you should simply be there for them. And try to encourage them to maintain their routines: sleep schedules, mealtimes, walks, etc. It's also important to remember to take care of yourself so you can be better able to support them.

Currently, there is no single, specific medical test to diagnose the disorder. Diagnosis is made after several clinical interviews, which require a comprehensive clinical examination. This includes a very detailed psychopathological assessment, as well as gathering information on psychiatric history, family history, psycho-emotional history, psychosocial development, and a physical examination, among other things. This is generally not done in a single interview, as it requires several sessions and the involvement of different professionals. The individual may also be asked to complete questionnaires or self-report forms to gather additional information and, based on all of this, arrive at a diagnosis.

Indeed, the average time to diagnosis for bipolar disorder is about 10 years . My hypothesis is that the delay in diagnosis stems from confusion with bipolar II disorder (which doesn't experience manic episodes, but only hypomania and depression). This diagnosis is more complicated because, often, a hypomanic episode can go unnoticed, leading the person to only consult a clinician when they are depressed, which can result in errors such as a diagnosis of unipolar depression. This rarely occurs with bipolar I disorder (where full manic episodes are experienced), as it's uncommon for a manic episode to go unnoticed. Other times, diagnostic errors arise from confusion between bipolar II disorder and certain personality disorders or anxiety problems, etc., since some symptoms are common to both conditions.

There is no specific food to avoid or consume to positively influence the disorder; however, a healthy diet based on vegetables, fruits, legumes, etc., and avoiding saturated fats and sugars, will have a positive impact on overall health, both physical and mental. This, along with healthy lifestyle habits that include physical exercise, rest, avoiding toxins, stress management, etc., will be key to feeling better on all levels.

This disorder is characterized by flare-ups, and relapses are a normal part of the process. However, it's usually possible to remain stable for extended periods by taking medication, maintaining healthy lifestyle habits (routines, sleep, rest, exercise, diet, and avoiding toxins), having regular appointments with your therapy team to identify any problems, and having the support of your social circle (friends, family, etc.). Perhaps one of these things isn't working properly, so it might be important to review all these aspects to see what isn't quite right. It would be beneficial to talk to your therapy team and close friends and family members so they can offer support.

I think the best thing to do is talk to the person affected. Tell them, with affection, respect, and empathy, that you think they might be experiencing euphoria and that you're there to support and help them. Encourage them to get more sleep and rest for a few days, and then contact the therapy team to confirm if this is indeed happening.

To do this, it's very important to build a solid foundation of relationship with the person who has bipolar disorder. Crucially, it's essential to develop a brief protocol together with the person you're caring for, during a euthymic phase. This protocol should outline how they would like you to proceed if what you describe were to happen. It's also helpful to include a list of the person's most frequent warning signs in this protocol, so you can refer to it and show it to them if needed. Include the phone number and email address of the people they want you to notify, and any other information you think would be useful for managing such a situation. As I mentioned, it's often very helpful to have all of this prepared during euthymic phases to know how to act in case of a crisis.

This is a very personal matter, and each family reacts differently, according to their own perspective. But, in general, my professional advice is that this diagnosis (like any other) should be communicated to the children, not only because of the genetic component it carries, but also because there will be times when the affected parent is experiencing symptoms or is hospitalized, and the child won't understand what's happening. In general, these kinds of secrets always affect family dynamics in the long run, so it's best to talk about it. And when doing so, the most important thing is to find the right moment and adapt what is said and how it is said to the child's age, giving them space to ask whatever they need and leaving the lines of communication open so they can ask questions later.

Yes, it's normal to feel anxiety and panic attacks during the phases, and it's also normal to experience the anxiety you describe even when you're not in any phase; that is, you can have panic attacks even when you're in a euthymic state. It's incredibly distressing because, as you describe, the feeling of impending death feels very real.

The best way to manage it is to work on it. There are currently effective and well-established psychological treatments for panic attacks, so my recommendation is that you seek help from a clinical psychologist to acquire the necessary tools to learn how to manage them.

When suffering becomes unbearable and there seems to be no way out, you must seek help immediately. Contact your psychiatrist or psychologist. Ideally, you should have a support network, which may also include family members. It is crucial to develop an emergency plan beforehand and share it with your network. Don't ignore these thoughts; seek help.

Poor adherence to treatment is something that affects not only people with bipolar disorder, but also occurs in other medical and psychiatric conditions.

Difficulties with treatment adherence never have a single cause, and each specific case must be analyzed to determine what might be going wrong. It's important to consider that, in addition to psychiatric disorders, there's the added burden of stigma, which can be a significant factor in medication discontinuation. Furthermore, the process of accepting that one has this type of illness, especially a chronic one, is often long and arduous. Taking medication daily serves as a constant reminder of this; sometimes, medication intake may coincide with times when privacy is lacking (for example, during work hours), which can hinder adherence. Another common reason for discontinuing medication is related to the side effects of these drugs or the fear of experiencing them. What I mean is that the cause is never singular, and each specific case must be evaluated to determine which of these or other factors are influencing the patient in order to work with them to address the root of the problem.

Here, too, I advocate for communication with the therapeutic team, if the person authorizes it. Ideally, the alliance between the person with mental health problems, the therapeutic team—which provides quality, verified information to family members and the person affected by bipolar disorder—and the family helps the process reach a successful outcome. Avoid infantilizing them; show great respect, and ask your family member, when they are well, what and how they would like to receive help during these processes.

The fact that a person "uses" their disorder to manipulate has absolutely nothing to do with any intrinsic or defining characteristic of bipolar disorder, but rather with aspects of that person's personality or the relationship in which this use of the illness takes place.

My advice is to make the person aware that this is happening so they can recognize this mechanism and help them find a way to communicate their needs without resorting to the disorder. This process is often complex, so professional help is frequently required.

Generally speaking, psychotherapy can help, but it's important to remember that in a case of delirium, medication is the treatment of choice. Whether psychotherapy helps or not depends on several factors: the severity and chronicity of the delirium, the relationship the patient has with their therapist, whether they have addressed the issue in previous sessions, and whether they have established a plan of action should it occur. However, it's crucial to remember that medication must be the primary treatment.

People over 65 years of age are a vulnerable population for developing problems related to medication use, mainly because:

• Aging is accompanied by morphological and physiological changes that modify the absorption of medications.
• Chronic diseases often occur simultaneously, requiring treatment with several medications over a long period of time.

Therefore, there is a greater risk of the drug accumulating in the body, causing undesirable side effects (excessive sedation, falls, overdose) without any greater therapeutic benefit.

In people over 65 years of age, professionals should be cautious when prescribing medication, taking into account possible drug interactions and medical conditions the person may have.

Treatment should be individualized for each patient, taking into account the risk and benefit of the medication.

In the human body, lithium is virtually undetectable under normal conditions and, therefore, is not related to whether a person follows a specific diet or is physically inactive.

Lithium is a medication used to treat and prevent manic episodes in people with bipolar disorder, among other mental health problems.

Lithium prescriptions should always be supervised by a specialist.

Yes, a person with bipolar disorder can relapse despite medication. While medication is essential, it's not the only factor in ensuring stability. As we mentioned in previous questions, it's also important to maintain healthy lifestyle habits : avoiding drugs and alcohol, getting enough sleep and rest, exercising, managing stress, nurturing relationships and emotional well-being, and so on. It's known that drug use, for example, can trigger a crisis, even with proper medication management, as can several sleepless nights. Furthermore, unforeseen circumstances can arise, such as seasonal changes, the death of a loved one, or even seemingly positive events like the birth of a child. These can generate so much stress that even with correct medication and healthy lifestyle habits, they could still trigger a crisis, although fortunately, this isn't always the case.

Knowing yourself is essential. There are signs that may be common to everyone, but there are also some that are unique to each individual. In general, these signs include changes in sleep patterns, eating too little or too much, irritability, or experiencing a period of greater stress than one can handle .

Take care of your sleep! Get up at the same time every day, and if you take naps, keep them to about 20 minutes. If you feel yourself relapsing, slow down, isolate yourself from external stimuli, take care of your body, and try to let music, art, or anything you enjoy fill you up. Writing is very therapeutic and helpful for getting to know yourself and learning to manage relapses.

Call your healthcare provider; don't wait. The goal is to stop the process and prevent it from becoming a crisis. In short: stop , breathe gently, and take good care of yourself.

The answer to this question would need to be personalized to each specific case, since every person I work with is different, and therefore, what works for one person may not work for another, and vice versa. However, as general guidelines, I would say that my approach to someone who has relapsed is always based on the utmost empathy and respect. The work I try to do in these cases involves supporting them through the process, focusing on learning and reflecting on what might have gone wrong that led to the relapse, analyzing the prodromal symptoms or warning signs, and trying to understand what went wrong in order to prevent it in the future. As we mentioned in previous answers, this fosters self-awareness in the person with the aim of preventing further relapses.

I imagine you're referring to a manic relapse. Yes, it's such a stressful time for the person and their brain that not remembering the episode or parts of it can be normal. In fact, it's quite common.

To be there for them, without many words. We know we're not doing well. Sometimes it's hard to explain. We're neglecting aspects of our lives that bring us joy. Sleep is disrupted…

Try to stay close to her, if you can, gently stroke her (if you think it will be well received), or at least make some physical contact. Look for comedies she can watch on TV. A shower is a very significant and important milestone. Celebrate it. The bed often becomes our cave and, at the same time, our prison. Very gently, ask if you can raise the blinds a little to let in some light.

Tell them you can't even imagine what they're going through, but that "you're here for them." Don't pressure them. Never, ever say, "Cheer up!" Any reasons you give will be useless, or almost useless. Offer your support with respect and affection.

I don't know if there are mobile apps for talking to professionals. Ask at your local clinics if they have any such channels. For example, at our unit, the Bipolar Disorder Unit (UBIP) at the Nuestra Señora de La Paz Clinic in Madrid, we understand the importance of being able to contact professionals when the first signs of relapse are detected. Therefore, we have established a communication channel with the people we treat (via email) so that requests are addressed as promptly as possible, in order to prevent most relapses.