Have you ever looked back on the day and wished you had done more? Or have you experienced any difficulty sticking to a waking and bedtime routine? Both are common problems, and a lack of regular circadian rhythm may significantly affect bipolar disorder.

What is circadian rhythm?

The brain’s hypothalamus gland controls the organ systems of our body via hormones, or chemical messengers. A fall in light (such as during the evening) is detected by our eyes then affects a group of cells called the Suprachiasmic Nucleus (SCN), or ‘master clock’; this in turn causes an increase in production and release of melatonin, which makes us sleepy.

This process provides us with a circadian rhythm, which can be affected by altered bedtime and waking times, shift work and jet lag.

By the way, our circadian rhythm is just over 24 hours long, as in ‘circa’ nearly and ‘dian’ day and it is believed to have significant effects on body temperature, stress-hormone cortisol, even regulation of mood and body weight1.

Why is circadian rhythm so important?

Dr Yoshikazu Takaesu2 of Kyorin University, Tokyo suggests “…circadian rhythm dysfunctions may act as predictors for the first onset of bipolar disorder and the relapse of mood episodes” and therefore that “treatments focusing on sleep disturbances and circadian rhythm dysfunction in combination with pharmacological, psychosocial, and chronobiological treatments are believed to be useful for relapse prevention.”

In an article published in The American Journal of Psychiatry, Dr Allison Harvey3 states that a high proportion of people with bipolar disorder are symptomatic between episodes; even in those receiving medication and psychological treatment. In particular, sleep disturbance affects quality of life and increases risk of relapse. She also suggests that daytime mood regulation can affect sleep and vice versa.

Dr Harvey also explains that it seems sleep disturbance escalates just before an episode and worsens still further during an episode. Although there appears to be an association, it is difficult to conclude from studies whether sleep disturbance is simply a feature of bipolar disorder, or a trigger for relapse.

How much sleep is enough?

A regular sleep/wake schedule of roughly eight hours sleep a night, seven day a week is proven to help protect against relapse, according to Dr Ellen Frank4, Professor of Psychiatry and Professor of Psychology at the University of Pittsburgh School of Medicine, Pennsylvania. She explains that many people with bipolar disorder are late chronotypes (as are their relatives), which essentially means you sleep later and wake later than the average person. Dr Frank suggests if you can work your schedule around your chronotype, this could give you the most restful sleep but then make sure to stay on that schedule.

How can we optimise our circadian rhythm?

In the world of chronobiology, “zeitgeber” (German for “synchroniser”) is an external cue that affects the body clock, such as light alerting us to the time of day. Early research by physiologist Jürgen Aschoff found that social cues such as mealtimes or work schedules can also act as zeitgebers5. Dr Ellen Frank recommends having three to four smaller meals per day to help keep mood and energy levels stable4.

The zeitgeber theory suggests that episodes of depression and mania or hypomania arise as a consequence of life events: a life event disturbs social zeitgebers such as mealtimes and bedtimes, and these changes then derail the circadian rhythm, triggering relapse5.

A treatment based on this idea, called “interpersonal and social rhythm therapy” (IPSRT), has been shown as effective in reducing relapse in bipolar disorder3. Several studies6,7 have shown that social rhythm therapy benefits people with bipolar disorder when added to medication.

As well as improving our circadian rhythms, having some sort of routine can assist us in setting and reaching time-based goals, which can improve mental health. For instance, small manageable goals can help lower stress from overwhelm and reduce unhelpful procrastination.

How do we end up with poorly structured days?

Routine can be disrupted through illness, whether it be physical or bipolar disorder. This can cause a multitude of symptoms such as poor motivation, low or excessive energy, low/high/unstable mood, poor concentration, and other problems with cognition such as difficulty with judgement and planning.

Life events such as loss of job, loss of regular social contact or interpersonal problems can also upset our balance.

Unhelpful thought processes where we over-identify with our thinking, known as cognitive fusion, can make it difficult to move forwards to a helpful behaviour. Examples might include: “I’m too lazy to do X” or negative thinking like “I’ll never get through everything I need to do. Might as well give up now” or “I don’t think I’m up to doing job Z perfectly so there’s no point.”

It is common human behaviour to experience habitual leaning towards ‘avoidant’ behaviours which usually make us feel better in the immediate moment (e.g. binge-watching TV or drinking excessive amounts of alcohol); unfortunately these avoidant behaviours are performed in place of healthier actions that could build our self-esteem and self-confidence because they follow our true values (e.g. going for a daily walk to improve physical/mental health, making sure to have a daily shower to practise self-care).

However, the thought of building a healthy, meaningful routine for ourselves can sometimes feel overwhelming.

Let’s look at some recommendations in line with Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy8 (ACT), where discovering and continually reviewing our personal values can help us to set useful personal goals.

What if I’m struggling to make changes?

Behavioural activation is an evidence-based treatment and maintenance therapy. It is one part of CBT and is used in mood disorders to increase a person’s positive behaviours and reduce negative ones.

Here’s an example of a negative behaviour cycle:

Sleep in for hours to avoid facing a task –>

Feel groggy and poorly motivated with low mood –>

Fell less able to perform the task –>

Experience low mood, motivation and feel guilty and frustrated –>

Sleep in late again.

On the other hand, a person making a conscious effort to perform a positive behaviour (even if they don’t feel very motivated and aren’t enjoying it) will usually find that when the goal has been achieved, their mood, motivation and confidence improve, making it easier to continue positive behaviours.

In addition to behavioural activation, it can help to explore our own values, in order to set meaningful goals.

Values & how they can help us set goal-orientated actions

Identification of values helps us work out our personal wishes and motivations, regardless of expectations from other people or society.

It is important to note that values are not describing our internal states (thoughts, feelings and emotions) as it would soon become clear that having a value of wanting to be happy and to always have positive thoughts would be impossible. Values are also not descriptions of how others behave towards us, as that is another thing we don’t have a great deal of control over either e.g. I want to be loved by person X.

By seeing where our current actions are aligned with our values, we are more confident in continuing and strengthening those actions. On the other hand, where we are not heading towards a value we feel is important, this can help focus our efforts. And if we are feeling ‘stuck’ and unsure as to what our values are, it can stimulate a thinking process to move us forwards.

We can prioritise the goals which will lead us to values we find most important. They can help us with time management. For instance, we may decide that initially we need to set aside ten minutes a day on a goal.

It’s also useful if we can keep an open mind for what comes up for us when we plan a goal or are actioning the goal. For instance, we may need to deal with negative thinking like “this needs to be perfect or there will be consequences” or cognitive fusion like “I’m too lazy to do Y”. Or we might spot potential barriers and decide how to work around them.

Some examples of personal values include

• Creative values e.g. to be imaginative, resourceful
• Experiential values e.g. to appreciate beauty in art, music etc., to love wholeheartedly
• Attitudinal values e.g. to be accepting of myself, to be accepting of others, to be fair, to be appreciative of things I have in life, to be open-minded
• Relationship values e.g. to be caring towards my partner/spouse, to bring up my child in a responsible manner, to be a loyal friend
• Achievement values e.g. to work hard, to improve my knowledge and skills
• Recreation values e.g. to regularly timetable leisure activities
• Health values e.g. to improve physical fitness, to look after mental health, to live life in a way that brings me spiritual meaning (e.g. regularly practising gratitude and patience, yoga, volunteering)

For a list of many more possible values, you could look at the ‘Card Sort’ exercise9 for inspiration and ideas.

From identifying which values are most important to you, and ones that could benefit from more attention, you have a starting point from which you can begin to set meaningful goals. You might simply categorise your values into Very Important all the way through to Not Important, or just choose the 5-10 most important to you today. As with all things, they are subject to change so review them when you feel ready.

Be SMART

The SMART acronym apparently first appeared in 1981 in Management Review. Since then, SMART has been used by a tool by countless organisations and individuals to help people identify and reach their goals. There are a few different versions, but we will use a commonly used one for the purposes of the article.

Don’t forget that we may need to break down a single goal into smaller ones, and more than one goal can run at the same time, so write down your ideas and plans.

To make sure your goals are clear and reachable, each one should be:

• Specific (who is involved, what do I want to achieve, where will it take place, why this goal)
• Measurable (how many/much or another indicator of success).
• Achievable (do I have the resources and capabilities).
• Realistic (is this sensible, do I have the motivation to commit to the goal). This one is especially important as people in a depressive phase might be more likely to set very low goals, and those in hypo/mania may set unrealistically high goals)
• Time bound (when do I wish to achieve this goal)

Reward yourself for completion of a goal if that helps, as some tasks are an effort and not always enjoyable.

Of course, setting and achieving goals is not always straightforward. Don Kattler10, a peer researcher for The Collaborative RESearch Team (CREST.BD) recommends that if you find yourself unable to reach a goal, first practise self-compassion (for instance “struggling to achieve is the human condition”, “I’m doing the best I can”), kindness and non-judgement. Next you could gently investigate any internal (e.g. feeling tired) and external barriers (e.g. insufficient time) that got in the way of success this time. Problem-solving an issue increases your chance of success next time. Another realisation might be that the goal was unrealistically high, so you might reduce the difficulty of the goal to maximise success.

And finally, don’t forget you can also check in with friends, family, your GP, psychiatrist or psychologist to if you need more support.

Dr Alice Lam – 10th October 2019

References

1. National Institute of General Medical Sciences. 2019. Circadian Rhythms. [ONLINE] Available at: https://www.nigms.nih.gov/education/pages/factsheet_circadianrhythms.aspx. Accessed 10 October 2019].
2. Takaesu, Y., 2018. Circadian rhythm in bipolar disorder: A review of the literature.. Psychiatry and Clinical Neurosciences, [Online]. 72(9), 673-682. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29869403 [Accessed 10 October 2019].
3. The American Journal of Psychiatry. 2008. Sleep and Circadian Rhythms in Bipolar Disorder: Seeking Synchrony, Harmony, and Regulation. [ONLINE] Available at: https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2008.08010098. [Accessed 10 October 2019].
4. (2019). Treatment Choices: Options for Bipolar Disorder. [Online Video]. 2 December 2014. Available from: https://www.youtube.com/watch?v=gzgi9Sr7twY&t=1137s. [Accessed: 10 October 2019].
5. Association for Psychological Science. 2016. Controlling Mood Disorders: A Matter of Routine. [ONLINE] Available at: https://www.psychologicalscience.org/observer/controlling-mood-disorders-a-matter-of-routine. [Accessed 10 October 2019].
6. Frank, E., 2005. Two-Year Outcomes for Interpersonal and Social Rhythm Therapy in Individuals With Bipolar I Disorder. Archives Of General Psychiatry, [Online]. 62(9), 996-1004. Available at: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1108410#26048444 [Accessed 10 October 2019].
7. National Institute of Mental Health. 2007. Questions and Answers About the STEP-BD Depression Psychosocial Treatment Trial. [ONLINE] Available at: https://www.nimh.nih.gov/funding/clinical-research/