Social rhythms in bipolar disorder: How daily behavioral patterns can increase vulnerability to both mania and depression

by Michael D. Anestis, M.S.

My dog got sick last night.  Why do I point this out in an article on PBB?  Quite simple, really.  As a result of my poor dog's illness, I did not get much sleep last night and, consequently, I'm experiencing a bit of a bad mood.  I suspect every person reading this article can relate to what I am feeling in this moment - a night of bad sleep leading to a morning characterized by irritability or other negative emotions.  Generally speaking, this passes within a couple hours and we forget all about it later in the day.  On a similar note, think about the last time you were extremely hungry and unable to find food.  Maybe you were rushed in the morning, missed breakfast, and went to work without time to stop and get a quick bite to eat.  Here again, I suspect everyone reading this article can think back to a time when this happened and remember feeling as though they were ready to bite the head off of the next person who asked them to do something.  Before long, these feelings fade as well, and the rest of the day typically goes smoothly.
    Researchers refer to our day-to-day routine, particularly with respect to basic processes such as eating and sleeping, as social rhythms.  Disruptions in these rhythms can cause anyone to experience a bad mood, but they are particularly problematic for individuals suffering from bipolar spectrum disorders (e.g., bipolar I, bipolar II, cyclothymia).  Research on social rhythms first gained prominence through the work of Ehlers and colleagues (1988), who published a theory referred to as the social zeitgeber theory of mood disorders.  If you are like me, you are currently thinking, "what the heck is a zeitgeber?"  Fair enough.  Zeitgebers are environmental "time setters," or cues that help regulate our circadian clock.  The simplest zeitgeber is the rising and setting of the sun, which for centuries has cued individuals to fall asleep and wake up.  Given that light is now readily available, humans now rely on a variety of other such cues.  Amazingly, simple day-to-day activities such as the timing of our meals or even our nightly schedule of television programming can have profound effects on our circadian clock (Frank, 2007).  Importantly, researchers have found that, in individuals with bipolar disorder, simple disruptions in social rhythms can prompt episodes of depression and particularly mania and prolong episodes that have already begun (Malkoff-Schwartz et al., 1998; Malkoff-Schwartz et al., 2000).  Shen, Alloy, Abramson and Sylvia (2008) found that individuals diagnosed with cyclothymia or bipolar II disorder engaged in fewer regular activities than did individuals with no mood disorder and that poor social rhythms predicted a quicker onset of mood episodes.  Ashman and colleagues (1999) found that individuals with rapid cycling bipolar disorder (four or more cycles of depression and mania/hypomania) demonstrated particularly dysregulated patterns of activity in the morning.  These findings seems to indicate that disruptions in our daily routine can make anyone vulnerable to a bad mood, but such disruptions in the lives of individuals with a bipolar spectrum disorder are particularly problematic and can lead to the onset and increased duration of both depressive and manic (or hypomanic) episodes.
    So what can be done about this?  Thankfully, an empirically supported treatment for social rhythms that can be used in conjunction with appropriate pharmacological treatment has been developed.  Interpersonal and Social Rhythms Therapy (IPSRT; Frank et al., 1994) aims to address three primary paths to relapse frequently seen in individuals with bipolar spectrum disorders:

1. Poor medication adherence
2. Stressful life events
3. Disruptions in social rhythms

IPSRT involves several components.  Clients are given medication adherence training in order to decrease the likelihood that they will cease using the mood stabilizing medications that have been shown to be, by far, the most effective means for stabilizing the dangerous mood patterns that characterize bipolar spectrum disorders, particularly bipolar I (Craighead, Miklowitz, Frank, & Vajk, 2002).  Additionally, clients are given a form on which they are taught to explore their feelings about their symptoms.  In doing this, clients are given a chance to grieve what Frank and colleagues have referred to as "the lost healthy self" in order to help them accept their current life situation and develop new perspectives and goals.  Such shifts in perspective often lead to a significant reduction in interpersonal and social role stress, which in turn can help reduce unhealthy fluctuations in social rhythms.  The goals of IPSRT can thus be summarized as ensuring the regular use of prescribed mood stabilizing medication, increasing acceptance of symptoms, developing goals based upon current life situations, and maintaining a stable, healthy pattern of eating and sleeping.
    In clinical trials, IPSRT in conjunction with proper pharmacological care has been shown to significantly increase the time between episodes of both mania and depression in individuals with bipolar I disorder (Frank et al., 2005).  In other words, when incorporated into treatment with medication, IPSRT increases the amount of time that individuals with bipolar spend symptom free.  Additionally, in bipolar I and bipolar II individuals experiencing depressive episodes, IPSRT resulted in a quicker remittance of symptoms (Miklowitz et al., 2007).  Perhaps the greatest measure of the effectiveness of a therapeutic intervention is its ability to reduce the most problematic outcomes associated with a particular ailment.  In this case, IPSRT has been shown to significantly reduce suicide attempts in individuals with bipolar disorder (Rucci et al., 2002).  IPSRT can be used both as an acute treatment for individuals currently in the midst of a depressive or manic episode or as a prophylactic treatment for individuals who are currently between episodes and seeking to maximize the amount of time spent without symptoms.  For individuals with bipolar I disorder (full manic episodes), IPSRT is best used in conjunction with mood stabilizing medication.  For individuals with bipolar II (hypomanic episodes, full depressive episodes), IPSRT can be used as a stand alone treatment if severity is not particularly extreme (Frank, 2007). 
    IPSRT consists of the following four phases, explained in more detail in Frank (2007).

Initial phase

• Obtain detailed history about the degree to which disruptions in social rhythms and interpersonal interactions have been involved in mood episodes.  This provides a rationale for treatment.
• Select area from the four interpersonal psychotherapy (IPT) modules that will be the focus of therapy (grief, role transitions, role disputes, interpersonal deficits).
• Typically lasts 3-5 sessions

Intermediate phase

• Develop healthy, regular social rhythms (e.g., sleep and eating schedule)
• Address the primary interpersonal area of concern selected during the initial phase of treatment

Continuation phase (or maintenance phase)

• Increase client's confidence that he can utilize these skills in his daily life, even when faced with life stress
• At this point, sessions are reduced from weekly to bi-monthly and, eventually, monthly.

Final phase

• Sessions are further reduced in frequency as termination becomes the goal

    The idea that regular sleep and eating patterns can impact our mood is not earth shattering news, although the empirical research examining this process certainly expands upon this point dramatically.  What is especially important to consider along these lines, however, is that individuals who are vulnerable to mood disorders must pay particularly close attention to the regularity of their schedules in order to reduce the likelihood of a mood episode.  Fortunately, as outlined above, empirically supported treatments are available that emphasize this point and train individuals to develop regular schedules that can be maintained even in times of stress.

For more information on IPSRT, we recommend the following products, all of which are available through our online store:
Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy (Guides to Individualized Evidence-Based Treatment)

For more information on bipolar disorder, we recommend the following products, all of which are available through our online store:
Cognitive-Behavioral Therapy for Bipolar Disorder, Second Edition
Managing Bipolar Disorder: A Cognitive Behavior Treatment Program Workbook (Treatments That Work)

For more information on interpersonal psychotherapy, we recommend the following products, all of which are available through our online store:
Comprehensive Guide To Interpersonal Psychotherapy
Clinician's Quick Guide to Interpersonal Psychotherapy
Mastering Depression through Interpersonal Psychotherapy: Patient Workbook (Treatments That Work)
Mastering Depression through Interpersonal Psychotherapy: Monitoring Forms (Treatments That Work)

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University