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Page 1
• Psychotherapy • Research • Training
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entre for
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nterventions
Module 3: Self-Monitoring for Relapse Prevention
Treatment Options for Bipolar Disorder
Keeping Your Balance
Module 3
Self-Monitoring for Relapse Prevention
2
3
4
Early Warning Signs Worksheet
A Plan of Action
Charting Your Life
Module Summary
5
6
7
8
10
Keeping Your Balance
The information provided in this document is for information purposes only. Please refer to the full
disclaimer and copyright statements available at www.cci.health.gov.au regarding the information on this
website before making use of such information.
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Treatment Options for Bipolar Disorder
SELF-MONITORING
How do we know that a storm is about to break? Perhaps we hear thunder in the
distance, the skies are dark and grey with rain clouds, and it becomes very windy. If we
do not want to be caught with the worst effects of the storm, we
would probably go back to our homes, close all the windows,
bring our washing in from the line, and secure any loose items outside the house.
Similarly, if bipolar patients become more aware of their early warning signs that
signal the onset of a mood episode, they can take steps to prevent a full-blown
episode of depression and mania.
Early detection of an impending “storm” – in the case of bipolar disorder, an episode of mania or
depression – can lead to early intervention and prevention of a mood episode. In order to be able to
detect an oncoming episode, bipolar patients must learn to recognise their own early warning signs and
symptoms of their illness. Each person has their own unique set of signs and symptoms although many will
be common to other patients.
It is not enough to be able to recognise and detect early warning signs and symptoms of a mood episode,
you need also to monitor them regularly. It will not be much good if you are aware of your early warning
signs and symptoms, but you continue to go through your daily life without paying much attention to the
onset of the symptoms. Similarly, a person who knows that ominous grey clouds, thunder, lightning, and
rushing wind signal an impending storm can still get caught in the storm if they were sitting on a park bench
too engrossed in a book to look around them. Therefore, regular self-monitoring is important for the
purpose of early intervention to prevent relapse.
Mood Monitoring
The first step to self-monitoring is monitoring your mood for the day. Ask yourself, “How did I feel today?
Was my mood within the normal range, or was I feeling slightly low or high? How low? How high?” Rate
your mood, between -5 (depressed) and +5 (manic). Try to rate your mood at the same
time every day.
Use the worksheet on the next page to monitor your moods. Try it for a week and see if
you can identify any pattern in your mood fluctuations. You might also want to take note of
the circumstances in which you experienced particularly high or low moods. Bring your
completed mood monitoring worksheets to your doctor or mental health professional and
discuss your observations with them.
Symptom Monitoring
Another way of monitoring yourself is to identify and be aware of any signs and symptoms associated with a
depressive, manic, or mixed episode that you might be experiencing. If you experience a number of these
symptoms over a few days, in such a way that they interfere with most of your day-to-day activities, you
might want to consider taking some action. We will talk about planning early interventions a little later on.
Use the worksheet on page 4 to record any symptoms that might have interfered with most of your day-
to-day activities.
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Mood Monitoring
Over the next week, monitor the fluctuations in your daily mood by filling in the mood graph below.
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Symptom Monitoring Worksheet
Each day, use the record sheet below and tick (4) to indicate if you have experienced any
of the symptoms listed in the table below, in a way that they have interfered with most
of your day-to-day activities. You might also want to record any observations you may
have about the circumstances in which you experienced these symptoms.
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Being Prepared
Identifying and Monitoring Your Early
Warning Signs
Early warning signs of a relapse or an episode recurrence are symptoms that typically
signal the onset of a mood episode. Some patients may think that they are not able to
predict an episode but researchers have found that many bipolar patients are able to
recall early warning symptoms that come before a full-blown episode. Bipolar patients have commonly
reported increased activity, decreased need for sleep, and elevated mood as early warning signs of mania,
and depressed mood, loss of energy, loss of interest in people or activities, impaired concentration, and
thoughts of death as early warning signs for depression. It was noted that although there was some
differences in the specific early warning symptoms experienced by patients, these symptoms appeared to be
the same within each patient in subsequent episodes. Thus, although some early warning symptoms may be
unique to individual patients, it appears that they are quite accurate in predicting the onset of a mood
episode for each patient.
Remember the Symptom Record in Module 1? If you completed that worksheet, you would have identified
and recorded your typical symptoms of mania and depression, and distinguished those from what you are
like when you are normal. To identify your early warning signs of mania and depression, a finer analysis
needs to be done. Ask yourself, “What am I like when my mood is mildly elevated and moderately
elevated? What am I like when I am mildly depressed and moderately depressed? Use the Early Warning
Signs Worksheet on the next page to record all these symptoms. When you have written them down,
reflect on the three or four most prominent early warning symptoms of mania and depression. Will you be
able to recognise these symptoms when you next experience them? It might be a good idea to discuss this
worksheet with your doctor or appropriate health professional.
Planning Early Interventions
The next step is to develop an action plan that details what you will do when you recognise the early
warning signs and symptoms of a major depressive or manic episode. The worksheet on page 7 can be
used to record your early intervention plans. It is important to be prepared so that when the time comes,
you will know what to do. Plan what you will do, what you will say, what you will ask your friends and
family to do for you, etc. For example, your action plan may include a visit to your doctor when you
recognise your energy level has increased and are feeling restless, or you may ask a
friend to keep your credit card when you have the urge to shop for shoes, or request
that a relative drop by to visit you when you stop calling them, etc. You may also want
to ask your friends and family to say specific things to you to highlight the possibility that
you might be becoming unwell. It’s probably good to let them know the best way to say
it so it doesn’t offend you. Detail your early intervention plans carefully and keep them
on your desk or on the refrigerator – somewhere that is easily accessible or visible – so that you can refer
to them when the need arises.
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Early Warning Signs Worksheet
What am I like when I am
mildly depressed?
What am I like when I am
moderately depressed?
What am I like when my mood is
mildly elevated?
What am I like when my mood is moderately
elevated?
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A Plan of Action
My most significant early warning signs are:
Early Warning Signs of Mania
Early Warning Signs of Depression
My plan of action for relapse prevention:
What I would do to prevent a full-
blown manic
episode
What I would do to prevent a full-blown
depressive episode
What I would ask my friends or family to do
for me
What I would ask my friends or family to do
for me
What I would ask my friends or family to say
to me
What I would ask my friends or family to say
to me
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Charting Your Life
Research has shown that for many people, their first episode was triggered by a major life stressor.
Subsequent episodes have also been linked with a stressful life event. Because of this, we encourage you to
think about and chart the course of illness in your life by doing a Life Chart. A life chart is a diagram that
illustrates the number, sequence, and duration of manic and depressive episodes, beginning from the very
first episode. The purpose of drawing a life chart is for you to track and identify patterns of recurrences,
early warning signs, and to see if there has been anything that might have triggered the onset of an episode.
As such, it is important that you include in your life chart the occurrence of significant life events and the
influence of treatment, such as medication and psychotherapy.
Below is an example of a life chart that tracks the course of illness in the life of a person, whom we will call
Jane Smith. Jane, a 37-year-old woman with bipolar disorder, experienced her first episode of depression
at age 20. This episode lasted almost a year and she got better without treatment. She got married and
her first child, a daughter, was born soon after. This was when she had her first manic episode, but she was
misdiagnosed as having a hormonal fluctuation. After her manic episode, she experienced a period of
severe depression and she was treated with antidepressants by her doctor. Two years later, Jane
experienced another bout of depression, which she associated with her being made redundant at work.
She was treated again with antidepressants, but this time it resulted in a manic episode. She was
hospitalised where she was diagnosed with bipolar disorder, and prescribed lithium. Jane found the lithium
helpful in controlling her symptoms and continued taking it regularly. However, when she felt better, she
realised that she had gained 10 kilos in weight and decided to stop medication. In a few weeks, she began
feeling better and more energetic. She started a few craft projects but she found herself doing more and
more. Soon, her symptoms were recognised as a manic episode and she was hospitalised. Several years
later, she again discontinued her medication and this time she experienced dysphoria and hypomania.
To draw a life chart, draw a line in the middle of a page. This line represents a “normal” state, that is,
normal compared to the times when you have felt depressed or hypomanic/manic. Next, mark the
extreme right point of the line as “Today” and draw in your current mood. On the extreme left of the
line, draw in your first recognisable episode of depression or hypomania/mania. Points below the line
represents depressed mood and points above the line represents elevated mood. The distance from the
reference line indicates the severity of the symptoms. The length of each episode is represented by the
width of each episode drawn in.
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You may find it easier to begin with the most recent episode and then work backwards. Talking with family
members or consulting medical records may also be beneficial. After you have completed your life chart,
take a good look at all the events you have recorded. Is there any pattern of episode recurrence? Is there
anything or any event that might have triggered a mood episode? Once you become more aware of the
things that affect you and your moods, you can take steps to be better prepared to deal with problems or
events that come your way. The ultimate goal is for you to become your own expert in dealing with and
managing your illness.
Conclusion
The purpose of mood-monitoring, identifying early warning signs, and doing a life chart is to help you
become more aware of yourself, your moods, and what is going on in your life so that you can manage your
illness better, make informed decisions, prevent further illness episodes, and ultimately have the quality of
life that you want. You may think that this makes you very focused on yourself and your illness or
problems. However, by monitoring your moods and symptoms, you can be more prepared for action to
prevent an episode from getting out of hand and ultimately endangering yourself. Thus, the benefits of self-
monitoring far outweigh the costs.
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Module Summary
• Regular self-monitoring is important for the purpose of early intervention to prevent relapse
• Mood monitoring involves rating your mood about between once a day, asking yourself, “How did I
feel today? Was my mood within the normal range, or was I feeling slightly low/high? How low (0
to -5)? How high (0 to +5)?”
• Symptom monitoring is all about identifying and being aware of any signs and symptoms associated
with a depressive, manic, or mixed episode that interfere with most of your day-to-day activities
• Bipolar patients commonly report increased activity, decreased need for sleep, and elevated mood
as early warning signs of mania, and depressed mood, loss of energy, loss of interest in people or
activities, impaired concentration, and thoughts of death as early warning signs for depression
• Identifying your early warning signs requires you to be aware of your symptoms when your mood
is mildly elevated, moderately elevated, mildly depressed, and moderately depressed
• It is important for you to develop an early intervention plan that details your most significant early
warning signs, what you would do, what you could ask your friends and family to do, and what you
could ask them to say to you to warn you that you might be becoming unwell
• Stressful life events can sometimes contribute to triggering a mood episode and it would be
important to be aware of how they affect you so that you can then be better prepared to deal with
them
• Consistent and regular self-monitoring and early intervention are the keys to preventing relapse
and episode recurrences
Keep Going ...
In the next module, we will discuss
a number of behavioural strategies
for managing and preventing
depression.
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Treatment Options for Bipolar Disorder
About The Modules
Contributors
Laura Smith (MPsych
1
)
Centre for Clinical Interventions
Dr Louella Lim (DPsych
2
)
Centre for Clinical Interventions
1
Masters of Psychology (Clinical Psychology)
2
Doctor of Psychology (Clinical Psychology)
Background
The concepts and strategies in these modules have been developed from evidence based psychological
practice, primarily Cognitive Behaviour Therapy. CBT for bipolar disorder is based on the approach that
adjunctive psychological treatment is helpful to improve understanding of the illness, medication adherence,
awareness of early warning signs of mood episodes, quality of life and to reduce symptoms.
References
These are some of the professional references that informed the development of modules in this
information package.
Basco, M.R., & Rush, A.J. (2005) Cognitive Behavioral Therapy for Bipolar Disorder (Second Edition). New
York: The Guildford Press
Bauer, M.S. & McBride, L. (2003) Structured Group Psychotherapy for Bipolar Disorder: The Life Goals
Program (Second Edition). New York: Springer Publishing Company
Goodwin, F.K. & Jamison K.R. (1990) Manic Depressive Illness. Oxford; Oxford University Press
Johnson, S.L. & Leahy, R.L. (2004) Psychological Treatment of Bipolar Disorder. New York: The Guildford
Press
Lam, D.H., Jones, S.H., Hayward, P., & Bright, J.A. (1999) Cognitive Therapy for Bipolar Disorder: A
therapist’s guide to concepts, methods and practice. Chichester: John Wiley & Sons Ltd
Miklowitz, D.J. (2001) Bipolar disorder. In David H. Barlow (Ed.) Clinical Handbook of Psychological
Disorders – Third Edition (pp 523-561). New York: Guilford Press
Newman, C.F., Leahy, R.L., Beck, A.T., Reilly-Harrington, N.A., & Gyulai, L. (2002) Bipolar Disorder: A
cognitive therapy approach. Washington: American Psychological Association
“KEEPING YOUR BALANCE”
This module forms part of:
Lim, L., & Smith, L. (2003). Keeping your Balance: Coping with Bipolar Disorder. Perth, Western Australia:
Centre for Clinical Interventions.
ISBN: 9780975198520 Created: March 2003
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