For the last few months, I’ve been experiencing a lot of anxiety about my current condition. I am stable, healthy, and well, yet I cannot help but shake the feeling that an episode is on its way. I’ve gotten so used to the depressive lows that nothing can convince me another one isn’t just on the horizon. No matter how much my therapist tells me I’m doing everything I can to maintain my stability, I can just picture myself hopeless and irritable again. And yet I wake up every day feeling strong and motivated. So to alleviate my fears, I decided to work on a prevention plan and share it with my family so they’d know what my trigger signs are and what to do if anything seems off. 

In bipolar disorder, a relapse is defined as the return of depression or a manic or hypomanic episode after a period of wellness. Sometimes it is possible to predict a relapse; often, it is not. For many, the onset of relapse seems to come out of the blue. Relapses will happen. It's perfectly possible to do all the right things, including eating well, exercising regularly, getting enough sleep, and still relapsing. It's essential not to feel like a failure when it does happen.

While the neurological causes of relapse are unknown, the best approach to preventing future episodes is knowing what activities may trigger a new episode of illness. Everyone's triggers are different – I figured if I learned to recognize mine, it might be possible to prevent or minimize the intensity of a bipolar relapse.

The following is a list of signs that I’ve identified in my previous episodes:

• Mania/hypomania early warning signs:
• Decreased need for sleep
• Begin to get lots of thoughts and ideas
• Feel “better than well”
• Increased energy
• Increased irritability
• Heightened senses – colors seem brighter, music more compelling
• Increased sex drive
• Feel more loving and expansive towards others – unless they disagree with me, in which case I am disproportionately annoyed
• Compulsion to keep talking, “pressured speech.”
• Jumping from thought to thought
• Jumping from project to project
• Aggressive or fast driving
• Impulse purchases
• Feeling impregnable, ‘bulletproof”, endowed with special powers or qualities
• Impatient, unable to wait in lines, frustrated by the “slowness” of others
• Unusually sociable, talking to strangers
• Paranoia, feeling people are talking about me behind my back, criticizing me, “ganging up” on me
• Argumentative, picking fights
• Taking on unusually large or ambitious projects that are impractical.

Depression early warning signs:

• Avoiding or withdrawing from others, refusing invitations or accepting invitations but not showing up
• Abandoning activities I usually complete and consider worthwhile, for example, reading books, playing with the kids
• Don’t go out, even if it is something I would usually consider “necessary,” such as a trip to the bank, or grocery store
• Don’t answer my phone or reply to emails
• Find it harder to get up in the morning
• Changes to sleep pattern such as difficulty sleeping, getting up later or earlier than usual, sleeping more than usual, taking more naps
• Harder to get going
• Stop eating, or overeating, especially “junk” or “comfort” food
• Pay less attention to personal appearance, hygiene, and grooming
• Feel slowed and sluggish
• Feel hopeless
• Feel down and sad
• Feelings of guilt
• Feeling tired
• Feelings of agitation
• Feeling irritable
• Feeling numb
• Feeling like I just can’t be bothered or motivated
• Not interested in things
• Not able to enjoy things as much
• Thinking is slowed and more difficult
• Hard to concentrate
• Self-talk is critical and blaming
• Difficult to think things through and make decisions
• Lots of worrying thoughts
• Ruminating thoughts  – thoughts that go round and round 
• Thoughts are negative about self, others, or the future.

What would I do to prevent a full-blown manic or depressive episode?

• I will maintain a regular, healthy sleep pattern. If things change, it should be a warning sign, and I should contact my therapist or psychiatrist
• I will keep up with my regular daily routine. If I find myself deviating from it, it should be a warning sign, and I should contact my therapist or psychiatrist. 
• I will set realistic goals for my personal and professional life to avoid disappointment and frustration, which can trigger a manic episode. 
• I will only drink alcohol occasionally and avoid completely illegal drugs as they make my symptoms worse.
• I will ask my support network (my mother, my siblings, and my best friends) to keep an eye on me and notify me if my behavior changes and I haven’t noticed
• I will reduce stress at work by keeping with regular hours and only taking on what I know I can handle. 
• I will keep track of my mood every day. When I see a pattern emerging or some mood swings, I will get in touch with my therapist and psychiatrist.
• I will take my medication religiously as prescribed to avoid taking risks or having unpleasant consequences from a potential episode. 

What would I ask my friends or family to do for me?

• I would ask them to keep an eye out for the trigger signs listed above.
• If they spot any irregularities in my behavior, I would ask them to talk to me and ask me what’s up. It may be a temporary inconsistency in behavior, or it may be a warning sign, and we could troubleshoot together.
• If I’m not cooperative and dismiss their concern, I would ask them to get in touch with my psychiatrist immediately and get me in for a check-up.

If I get another episode, I can guarantee it will not be because of illegal drug use or non-compliance with my treatment. So please be patient and don’t blame me for fucking it up.

I’m a recovering smoker. I still smoke cigarettes like a chimney, but it’s over a year since I quit smoking cannabis. It took me a while to quit after my episode. I wasn’t convinced that cannabis had exacerbated my mania and led me to psychosis. I had self-medicated with cannabis for so long that I couldn’t grasp the concept that it could harm me in any way. It took a lot of research and multiple discussions with my medical team to finally understand the implications of smoking pot regularly in my condition. 

At present, it looks like more research is required to honestly assess the effects of cannabis on people with bipolar disorder. That being said, research does suggest that marijuana can increase the risk of suicidality and psychosis. So, if you have bipolar disorder or have a family member with bipolar disorder, it’s advisable to be very careful about using cannabis.

Some researchers have found that marijuana use can make symptoms of bipolar disorder worse in some people. This review found that using marijuana could worsen manic symptoms in a person with bipolar disorder. They also found that marijuana use could trigger a manic episode.

According to another study, suicide attempt rates in people with bipolar disorder were higher in those who used marijuana than in those who didn’t use marijuana. The study also found that people who used marijuana were younger at bipolar disorder onset (when their symptoms started) than those who didn’t. This is a concern, as doctors think that a younger age at onset causes worse symptoms throughout a person’s life.

In one study, patients who quit using marijuana or reduced its use following their first psychotic episode had the most significant improvement in symptoms at the one-year mark compared to continuing cannabis users and people who had never used cannabis. (yay for me!)

None of these studies proves that cannabis is actually causing these problems in people with bipolar—they just show an association between marijuana use and problems. But you should factor this information into your thinking when deciding whether or not to use cannabis.

Some people have reported positive effects, such as improved mood. But others have said negative consequences, such as worsened mania or suicidal thoughts. Further research is needed on marijuana’s effects on bipolar disorder and the long-term effects of prolonged use.

What doctors do know is that marijuana isn’t as effective as prescription medication and therapy can be in managing the symptoms of bipolar disorder. So if you have this condition, stick to the treatment plan prescribed by your doctor.

How to quit using cannabis
I quit cold turkey. When my supplies dried out, I told my psychiatrist that I was about to quit, and he prescribed Seroquel to take around bedtime, which would help with sleep. I cut off my friends who were regular smokers and surrounded myself with positivity and reminders that being sober would dramatically improve my moods and help me regulate myself. In this past year, I have smoked twice. Once on my birthday and once when I was vacationing on a deserted island surrounded by coconuts and white sand beaches. A couple of months after I’d stopped, I dreamed about smoking every day; I thought it would go on forever.  But nowadays, I only occasionally have those dreams, and they don’t bother me so much. This time I made a conscious decision to stop, and I’m always mindful of the inevitable results of starting up again (addiction, insanity), which outweigh any short-term positives of getting started again. 

The scariest part of quitting is the withdrawal symptoms. They’re mainly psychological and are not as severe as withdrawal from other commonly abused drugs.

Signs and symptoms of withdrawal include but are not limited to:

• Insomnia.
• Anxiety.
• Drug craving.
• Irritability.
• Low appetite.
• Unusual dreams or heightened activity during sleep.
• Restlessness.
• Abdominal pain.
• Tremors.
• Sweating.
• Fever.
• Chills.
• Headache.

Don’t be discouraged by this long list. You’re likely only to experience a few of them at a time. The withdrawal for hash and marijuana begins within 24-72 hours of stopping use, usually peaks within the first week, and tapers off approximately 2 weeks after the last ingestion. For some, sleep difficulties may last more than 30 days.

If you have bipolar disorder and want to quit smoking, talk to your doctor, he will arm you with the right tools to handle this transition. 

Some tools that helped me quit (more resources and strategies here):

• Getting rid of my gear: I collected all my paraphernalia and stored them in a box I donated to my friend. That included grinders, papers, storage boxes, and lighters.
• Making a plan to deal with triggers: whether it’s a group of friends that constantly smoke or certain situations where you’d want to light up, make sure you know what your triggers are and how you’ll deal with them when they arise. 
• Varying your routine: If you’re used to smoking in the morning, replace that with a 10-min meditation. If you like to smoke after work, try a long warm bath.
• Picking a new hobby: The key is to keep yourself occupied. You could take up journaling or learn a new skill on Coursera. Anything to replace the hours you used to waste smoking will do.
• Getting help for withdrawal symptoms: You might need sleeping aids to help with insomnia. Other symptoms may be managed with your doctor or with simple techniques such as drinking less coffee, meditation, deep breathing, and drinking plenty of water.

When the quarantine started, I looked into online courses I could take, and I stumbled upon the Foundations of Positive Psychology Specialization on Coursera. Through my work, I was already familiar with the science of character strength and the VIA survey, and I wanted to learn more about the core tenets of positive psychology. My colleague further encouraged me to pursue this specialization when he realized that Martin Seligman, one of the founding fathers of positive psychology, was one of the instructors. 

Positive psychology is the scientific study of positive human functioning and flourishing on multiple dimensions of life (biological, personal, relational, institutional, cultural, etc.). What holds the highest value in life and contributes the most to a well-lived and fulfilling life? In positive psychology, researchers have shown that diverse strategies such as expressing gratitude, savoring experiences, using strengths, increasing optimism, and practicing kindness all demonstrate the potential to boost an individual’s level of well-being.

Seligman proved that a meaningful life has to include 5 factors, captured in the acronym PERMA:

• Positive emotions connected to positive outcomes, such as longer life and healthier social relationships
• Engagement or involvement in activities that draw and build upon your interests
• Relationships, whether they are work-related, familial, romantic, or platonic
• Meaning, aka. Purpose. Despite potential challenges, working with meaning drives people to continue striving for a desirable goal.
• Accomplishments are the pursuit of success and mastery

Naturally, I got curious and researched how positive psychology had influenced the treatment of bipolar disorder. Several studies show that positive psychology interventions improve well-being and lower depression levels. I wanted to know more and reached out to the source himself. I emailed Martin Seligman on a Sunday and asked him which, if any, of the positive interventions were helpful to the treatment of bipolar patients. He replied, to my great surprise, to try all of them!

Without further ado, here are some of the most prominent positive interventions in the field of positive psychology, hoping one of them might help someone with bipolar disorder feel a little bit better. 

If you’re feeling up for it, measure your current happiness today and then measure it again after you’ve tried one of the interventions below. You’ll be surprised at the results after implementing those simple changes.

Assess your happiness
a) Your overall level of happiness with life: General Happiness Survey
b) Your current mood: Positive and Negative Affect survey, PANAS
Find the questionnaires here.

The ‘What went well’ Exercise
As a species, we are generally oversensitive to the threats in our environment and overlook the positives. The gratitude diary is one of the most straightforward techniques scientifically proven to boost happiness.
Every day for the next 2 weeks, and then once a week after that, simply write down 3 good things that you are grateful for that have occurred recently.
Doing this exercise for 2 weeks has been shown to positively affect happiness for up to 6 months. It helps rewire the brain to scan for the positives and helps you better notice and pay attention to the things that bring you joy.

Daily Mindfulness
Mindfulness is a way of paying attention to the present moment. When mindful, we become more aware of our thoughts and feelings and better manage them. Being mindful involves staying in the moment and noticing what's happening inside ourselves and our surroundings. Rather than trying to change things, it consists of accepting how things are, for better or worse.
Take 10 minutes each day to do a simple mindfulness meditation. Try apps like Headspace or Insight Timer for many free meditations.

Gratitude Letter and Visit
Studies show that expressing our gratitude to others can significantly boost our happiness. It can also have a powerful effect on the recipient and help strengthen your relationship.
Think of three people who have positively influenced your life and for whom you feel really grateful. They could be a member of your family, an old teacher, a long-lost friend, a colleague, or someone else who has made a real difference in your life
Now you can choose one of these people to write to and tell them how grateful you are; perhaps someone you've not appropriately thanked before. Think about the impact this person had on you and write a letter to tell them:

• What specifically are you grateful for?
• How did they help you?
• How did it help make you the person you are today?

You can write the letter any way you like – but try to be really in touch with the feeling of being
grateful to them as you write. If possible, could you arrange to visit the person and read the letter aloud to them? Otherwise, post or email the letter to them and follow up with a phone call.

Random Acts of Kindness
Doing things to help others is not only suitable for the recipients but also has a positive payback for our happiness and health. When people experience kindness, it also makes them kinder – so kindness is contagious! The saying goes: "if you want to feel good, do good."
Could you perform an extra act of kindness each day? This could be a compliment, a helping hand, a hug, a gift, or something else. The action may be large or small, and the recipient may not even know it.

The ‘Signature strength’ Log
Understanding and using our strengths is about focusing on the things that come most naturally to us and that we love to do. Research shows that using our strengths in new ways can make us happier even after just one week! 
Assess your strengths and then focus on using these in new ways. 
First, identify your strengths with the VIA Character Strengths assessment here (takes up to 30 minutes)
Pick one of your top 5 strengths and ask yourself:

• How do I use this, and in what areas?
• What are other areas in my life that I could use more?
• What are other ways I could use it?

Every day over the next week, try to use this strength in a new way or a new area of your life.
Repeat the following week using another of your top five. And so on.

For a comprehensive list of positive psychology exercises, you can visit the ultimate resource here and here.

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If, like me, you have experienced psychosis, then you know it is not easy to talk about it with other people. I’ve done a lot of research on bipolar disorder to understand my condition and learn to manage it, and I’ve found very little information about bipolar psychosis. I’ve had one major psychotic episode, and I know that about 60% of people with bipolar disorder experience psychosis at least once in their lifetime, so I decided to do some research and gather some thoughts about this topic.

Currently, I am not actively psychotic or having an episode. And at this point in my life, I feel I know myself better than I ever have, and I am learning how to make this life work for me.

Here are some facts I’ve gathered to help me make sense of this condition.

What is bipolar psychosis?
It is a distorted or nonexistent connection with reality. A person with psychosis cannot distinguish between the external, objective “real world” and their own subjective perceptions, distorted and characterized by delusions and/or hallucinations.

In bipolar psychosis, this loss of contact with reality is usually a feature of the severe mania experienced in Bipolar Type I. However, it can also be associated with bipolar depression, but this is far less common. People with bipolar I can share a broader range of symptoms than those with bipolar II, but both can go through psychosis.

It is characterized by grandiose delusions involving exaggerated feelings of power, wealth, sexual attractiveness, luck, or insight. It is also characterized by hallucinations which include hearing, seeing, feeling, smelling, or sensing things that are not really there. 

There is a great deal of information about bipolar disorder and psychosis on the Black Dog Institute Factsheet and Psychology Notes.

> The psychotic episode I had had delusions and hallucinations, and I recount parts of that episode in the earlier posts of this blog. I’m still processing that episode as I am shocked that my mind could lose its footing severely and put me in danger. It’s something I often revisit in therapy.

What to do during bipolar psychosis?
Here are three things that have helped Pippa L. when experiencing psychosis.

#1 Deep breathing
Count to ten and let your breathing settle down. Sometimes the correct breathing pattern can be enough to settle or even stop the psychosis. Make sure your breaths are even deep and continue until you feel calm and safe.

#2 Safe place
You may not be able to prevent psychosis, but you can lessen its effect on you. Get yourself to a safe place, or at the very least, to a quieter place. If you can, grab someone you trust and take them with you, or go alone if that makes you more comfortable.

#3 Anchoring objects
You can find things around you that you can focus on. Some great apps are available for further help if necessary, but just find something still and focus your attention on that object as much as possible. Psychosis can only affect you to the extent you are concentrating on it.

> I found these grounding strategies helpful as I was lost and confused while experiencing my psychosis. Some moments were panic-inducing, so I’m adding them to my toolbox in case this happens again.

How to treat bipolar psychosis?
You have to treat psychosis with antipsychotics immediately because it can be dangerous to lose touch with reality.

People with bipolar disorder who are experiencing psychosis are usually prescribed what are called atypical antipsychotics, or second-generation antipsychotics, according to the NIMH. They work by affecting various neurotransmitters in the brain, including dopamine.

Antipsychotics begin to treat some symptoms, like hallucinations, within days, while it may take weeks for delusions to fully recede.

The duration of treatment is highly variable, depending on the patient. Some people with bipolar disorder only take antipsychotics when symptoms appear and stop a few weeks or months after they feel normal again. Others may stay on a low dose of antipsychotics for a year before tapering off to prevent another episode. And sometimes, people stay on them indefinitely as a maintenance treatment.

Most often, antipsychotics are just one component of the drug regimen used to treat bipolar disorder.

> I’ve been on Abilify since October 2018, and my psychiatrist recently told me we will discontinue its use (which was the best news ever as I can’t take the weight gain anymore). 

The best way to manage psychosis is to prevent as many mood episodes as possible. The longer a person with bipolar disorder can stay stable early in their illness, the better their prognosis in the long term. Achieving that stability usually entails sticking to a treatment plan, including medication and therapy, and avoiding episode triggers like extreme stress, sleep deprivation, and substance abuse. It also involves checking in with a doctor often and adjusting that treatment plan as needed.

While I am still processing my psychotic episode, I find that knowing is just half the battle and this information helps me make more sense of what I went through with the hope that work in therapy will allow me to dig deeper and really figure out what went down in that complex mind of mine.