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Bipolar Disorder: Relapse Warning Signs

Bipolar disorder is a lifelong condition defined by extreme emotional highs (mania) and lows (depression). These highs and lows are accompanied by dangerous behavior changes. An important part of managing bipolar disorder is recognizing the early warning signs of these extremes.

Early warning signs are thoughts, feelings, and behaviors that act as red flags signaling an oncoming relapse. Recognizing early warning signs allows a person to seek help before symptoms get out of control, which has been found to reduce hospitalizations, and improve well-being.

This guide will provide information on spotting early warning signs and identifying an individual’s “relapse signature.”

Note: Learning to identify and use early warning signs is part of a broader treatment for bipolar disorder, conducted by professionals, that often includes medication and other interventions.

The Onset of Mania and Depression

The Timeline of a Mood Episode

Prior to an episode of mania or depression, during a period called the prodrome, the earliest signs and symptoms of an episode begin to appear.

The prodrome is divided into two sections: early prodrome and late prodrome. The early prodrome has mild symptoms, and can start up to 4 weeks before an episode. The late prodrome has increasingly severe symptoms, and can start days or hours before an episode.

The signs and symptoms of the prodrome are the early warning signs of depression and mania. It’s during this period that steps can be taken to reduce or stop symptoms, before they grow into a full-blown episode. Once an episode begins, symptoms become more difficult to control.

Baseline

normal mood and behavior

Early Prodrome

  • earliest symptoms and warning signs begin to appear
  • may begin days or weeks before a manic or depressive episode

Late Prodrome

  • symptoms of the early prodrome progress and become more severe
  • may begin days or hours before a manic or depressive episode

Mania / Depression

symptoms of a mood episode begin and become more difficult to manage

Common Warning Signs: Mania

Mania is characterized by a feeling of high energy, pressure, anxiety, and intensity. Someone who is experiencing mania may seem “amped up” and become more likely to engage in risky behaviors.

Early warning signs for mania involve shifts in mood, perception, thoughts, and behavior. Many of the changes feel good in the moment, but they carry long-term negative consequences.

Common early warning signs for mania include the following:

More energetic Feeling “high” or “in another world” Easily distracted Senses seem sharper / colors more vivid
Ideas flow quickly More talkative Suddenly feeling creative Irritability
Spending money more freely Sleeping less Anxiety Feeling rested even with little sleep
Increased sex drive Feeling especially strong or powerful Drinking or drug use Elevated feeling of importance

Common Warning Signs: Depression

Depression is characterized by feeling sad, slowed down, or low on energy. Someone who is experienceing depression may lose interest in things they previously enjoyed and withdraw from normal life activities.

Early warning signs of depression involve changes in thoughts, feelings, behaviors, and physical symptoms. Sadness is the defining feature of depression.

Common early warning signs of depression include the following:

Sadness Ideas feel slowed down Difficulty focusing Senses seem duller
Less talkative Less interest in people and activities Less energetic Anxiety
Worry Restlessness Aches and pains Drinking or drug use
Irritability Social isolation Decreased sex drive Sleep problems (too much, too little, or disrupted)

Strategies for Spotting Early Warning Signs

Identifying early warning signs takes practice. Before a person knows their early warning signs, they’ll often go unnoticed. When this happens, the symptoms are likely to evolve into a full-blown episode of mania or depression.

By building awareness of day-to-day mood changes and reflecting on the missed warning signs of past episodes, these unnoticed changes can become a powerful alarm system.

Track Mood and Behavior

Before recognizing changes in mood and behavior, it’s important to establish a baseline. Taking a baseline builds awareness of how a person usually feels and behaves, which highlights when changes are occurring.

For example, someone who is always sociable and energetic should not be alarmed by having a calendar full of social events. However, this might be a red flag for someone who usually keeps to themselves.

Instructions: Complete a daily mood log to track mood, sleep, and other common warning signs. Aim to make this a long-term daily habit. With consistency, you’ll improve at noticing warning signs.

As you continue completing mood logs, pay special attention to fluctuations in mood and behavior, even if they seem minor. These might be the first warning signs of a mood episode.

Tip: Want to make completing the mood log a habit? See our worksheets on building healthy habits:

Explore Previous Episodes

Many people with bipolar disorder find that their depressive and manic episodes start in similar ways every time. For one person, this might mean fast speech and a sudden increase in ambition. For another, it could be changes in diet or sleep patterns.

By reviewing past episodes, overlooked patterns and clues will emerge.

Tips for Exploring Mania & Depression
  • Review several previous episodes. It’s helpful to start with recent episodes because the details are still fresh. However, first episodes and especially severe episodes can also be good choices.
  • Think about what happened before each episode. Instead of focusing on the peak of an episode, try going further back. Look for warning signs that may have appeared in the days or weeks before the episode was in full swing.
  • Compare episodes. The most helpful warning signs are the ones that are consistent. Look for patterns and similarities between episodes.
  • Ask friends & family for their observations. Oftentimes, it’s easier to see warning signs from an outside perspective. In some cases, family members will be invited to therapy to share their observations.

The Relapse Signature

A relapse signature is a set of 4-6 warning signs, unique to each person, that consistently predicts a manic or depressive episode. Learning to spot these patterns is the key to catching future mood episodes before they are in full swing.

A relapse signature isn’t just a list of warning signs—it’s also the order in which they appear, and how they progress. When it comes to mania, loss of insight typically marks the end of the relapse signature, and the start of a manic episode. After losing insight, it is especially difficult to regain control.

    Learning Relapse Signatures
  1. Choose a past episode of mania or depression to explore.
  2. Write each warning sign on a notecard, one warning sign per card. If exploring mania, write “loss of insight” on one card to mark the end of the warning sign stage.
  3. Put the cards in the order the symptoms appeared.
  4. Repeat this process for a second episode of the same type.
  5. Compare the episodes. Use this information to create a single progression order that is generally accurate.

Example: Robin notices a gradual increase in energy starting a week before a manic episode. As the week progresses, the energy leads to socializing more. By the time an episode is about to begin, Robin is staying out late, and getting little sleep.

Robin's mania relapse signature:
  1. Gradual increase in energy
  2. More socializing than usual
  3. Staying out late
  4. Sleeping less

Relapse signatures should be recorded, reviewed regularly, and shared with family members or close friends who can help. Regular check-ins with a mental health professional can also be used to monitor symptoms or changes related to the relapse signature.


Conclusion

Understanding your relapse warning signs is a powerful tool for reducing the severity of future mood episodes, or heading them off completely. Knowing about an episode before it takes control will give an opportunity to seek professional help, take practical safety measures, and avoid high-risk situations.

1. Grunze, H. (2015). Bipolar disorder. In Neurobiology of brain disorders (pp. 655-673). Academic Press.

2. Miklowitz, D. J., & Gitlin, M. J. (2015). Clinician's Guide to Bipolar Disorder. Guilford Publications.

3. Morriss, R. (2004). The early warning symptom intervention for patients with bipolar affective disorder. Advances in Psychiatric Treatment, 10(1), 18-26.

4. Perich, T., Mitchell, P. B., Loo, C., Hadzi-Pavlovic, D., Roberts, G., Frankland, A., ... & Wright, A. (2013). Clinical and demographic features associated with the detection of early warning signs in bipolar disorder. Journal of Affective Disorders, 145(3), 336-340.

5. Sahoo, M. K., Chakrabarti, S., & Kulhara, P. (2012). Detection of prodromal symptoms of relapse in mania & unipolar depression by relatives & patients. The Indian Journal of Medical Research, 135(2), 177.

6. Spotting Icebergs From Miles Away: How to Use Early Warning Signs in Bipolar Disorder Relapse Prevention. (2016, October 14). Retrieved November 30, 2020, from https://ibpf.org

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