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Before me move into talking about medical treatment, this is the Instability Model and
it was originally proposed in 1990 by Fred Goodwin, remember I talked about before and
Kay Jamison who's also a big time well-known Bipolar researcher and Kay Jamison also suffers
from a very severe case of Bipolar 1 disorder herself. And she's one of a group of courageous
people who've had mental illnesses and had the courage to come out and be public about
this and I think that goes a long way to reducing some of the stigma. Their book, called "Manic
Depressive Illness" came out in the second edition three years ago. It's about four inches
thick and it's probably the definitive bible on Bipolar disorder so if you really want
to go to the best source that's a good one to look at. Anyway, the Instability Model
has to do with the notion that there are environmental and lifestyle factors that are extraordinarily
critical in maintaining stability in Bipolar disorder. And people, we all have a built
in circadian rhythm and circadian rhythm tends to not be completely in synch with a 24 hour
day, for reasons that are not well understood. If you look at groups of people the circadian
rhythm is actually about 24 and a half hour rhythm. And so if left on its own it'll drift,
it'll be out of synch. The circadian rhythm has so much to do with things like sleep and
wake cycles obviously but also very predictable diurnal changes in body temperature, in the
secretions of certain hormones that occur during parts of the day. Cortisol For instance
is very high during the morning, growth hormone is released almost exclusively during slow
wave sleep at night, the function of the immune system and on and on and on. The circadian
rhythm, if it maintains its stability, also facilitates stable brain functioning. Now
most of us can get away with violating things that throw a wrench in the circadian cycle.
We can travel across time zones, experience jetlag and we certainly don't end up in the
hospital with psychotic mania if we travel to the east coast. But people that have Bipolar
disorder among all human beings are probably the most sensitive to having disruptions of
their circadian cycle be a destabilizing force. And this has led to interventions- certain
kinds of psychotherapies and lifestyle interventions that have shown to be very very helpful in
with Bipolar patients. And I can't begin to think that a person even has a shot at surviving
Bipolar unless they take their medicine and adjust their lifestyle. So this is the model.
Now for most well not for most- for human beings, what regularizes and stabilizes the
circadian rhythm has to do with the first dose of light you get in the morning. Human
beings evolving for five million years at the equator got used to in their physiology
developed around and organized around certain environmental- predictable environmental stimuli
and one those is at the equator the sun comes up at the same time every day, 365 days a
year, give or take just a few minutes okay. So getting bright light is what normalizes
circadian rhythmicity. It's like if you have a watch that runs fast and you have to reset
it each day and it's more or less okay to use each day but you have to reset it every
morning so it's operational, the circadian rhythm is the same thing. What stabilizes,
what is called entrainment that normalizes circadian rhythm primarily has to do with
the first dose of light each day at the same time but also extraordinary regularity in
a number of different domains in our daily life. Like the time of day that you eat, the
time of day that you exercise, the amount of bright light that you get 365 days a year
that when lifestyle adjustments are made in the direction of enormous regularity people
simply do better okay. So that is their model. So this is what's recommended. Regular times
to go to bed and to wake up. Now, it's looking more and more like what really matters most
is getting enough sleep and waking up at the same time each day. People can go to bed and
make themselves go to bed at the same time each night but that doesn't mean they're going
to fall asleep. But ultimately people have control over when they wake up. I mean you
can make yourself get up. People do that all the time to go to work. And I'll tell you
some of these lifestyle things I'm not especially wild about doing, I would've much rather slept
in this morning, I don't know about any of you. But try to get Bipolar teenagers to wake
up at 6:30 on Saturday or Sunday morning okay. They're not gonna wanna do that but this is
not a small issue, these are high yield interventions okay. What Jamison and Goodwin found and of
course these are large group-scale studies is the people that do best with Bipolar illness
over years are those that get regular basis between 7 and nine hours of sleep a night.
Those that get less than that or more than that can be more unstable. So what you want
to try to do is get adequate amount of sleep but the key factor here is waking up at the
same time each morning. But it's not just waking up, it's getting some light. And I
think we talked about dawn simulation in an earlier class. It doesn't have to be sunlight,
because if you wake up at 6:30 in the winter sometimes the sun's not up, but simply turning
on the light in your bedroom you know, so it's waking up and getting some light that
helps to regularize the circadian rhythm. There's a therapy approach called social rhythmic
approach to therapy that we'll talk about in just a minute but it also includes maintaining
social rhythms. Now what this means is one, to avoid intense emotional interpersonal stuff
in the evening time. People have arguments or heated discussions or what have you it
tends to make it harder to go to sleep or especially to get into your first episode
of deep sleep. Sometimes this is hard to avoid but people do have some choice you know about
when they're gonna bring up issues and they need to do it earlier in the day. Every time
you eat you change the chemistry of your body. Most of us we can have very irregular times
when we eat and overall it doesn't make that much of a difference. But here, this having
great regularity about the time that you eat can make a difference okay. Exercise. Exercise
is great for combating depression and people exercise less in the wintertime than they
do in the summertime. This may be a contributing factor to their being a lot more depressions
in the winter with Bipolar. So the goal here would be to normalize the amount of exercise
that you get year round okay. So if it's 15 minutes a day on the treadmill or something
do it year round. Also the amount of bright light exposure, I think I may have mentioned
this in our last class but with Bipolar you get a lot more manias in the summertime. Anything
that treats depression can provoke mania and bright light therapy treats the depression
okay so you want to have the same amount of exposure 365 days a year. Okay again lifestyle
choices that a lot of us find to be a real pain in the neck but they're high yield. Whoops.
what's happening here? stop that. Okay. These are really poison for Bipolar disorder. Shift
work? Forget it. You just can't do it. Now shift work, it's not just working the night
shift, it's you work for six weeks night shift and then you switch to graveyard and then
you switch to daytime every six weeks or so. And there are a number of people who have
jobs like that but it's just too disruptive okay. Time zone changes. It's dicey. I had
two physicians that had their first manic episodes, one of them went to Europe and one
of them went to Asia. Both of them ended up getting hospitalized overseas for having their
first manic episodes. I keep talking about these physicians, after I left Kaiser I got
about ⅔ of my practice work were physicians and maybe a disproportionate rate of physicians
but anyway, two guys in the same year just got horribly psychotic because of time zone
changes. and I've had a lot of people talk about this either that has Bipolar or a spouse
say "We really wanna go to Europe but I've read about time zone changes and what do you
do? The best thing to do is not go to Europe. Try and stay in your own time zone if you
can but people also wanna have a life too. So, I think it means number one, it is you
anticipate this ahead of time. And the person that has Bipolar talks with their prescriber
and probably it's wise to begin to increase the dose of especially anti-manic drugs. It's
especially mania that's more likely to get provoked by time zone changes. To give a better
safety net, plan to instead of trying to do a 24 hour nonstop kinda I mean I've done this
in Europe where I've had layovers and you get there and it takes 20 hours or something
like that, is fly to the east coast, take a day, sleep, I mean just stuff like that
would make a lot of sense. But to be extraordinarily cautious and also really really avoid the
use of alcohol. And on international flights they're very generous with their alcohol I've
noticed. Substance abuse and obvious thing and disrupted sleep. When I was in grad school
I worked at the counseling center at Baylor where I went to school and we would have these
freshmen usually get brought into the health center and they were crazy, they were psychotic,
they were manic, and it wasn't infrequent at all for this to occur right around the
time of their first semester of midterm exams and they'd pulled a couple of all-nighters.
You know and sleep disruption is a very potent factor in causing especially manic episodes,
so just lots of attention needs to be devoted to maintaining good sleep habits.