What is… ultra rapid cycling

In this series, I dig a little deeper into the meaning of psychological terms.

This week’s term: ultra rapid cycling in bipolar disorder

Rapid cycling is a term used to describe the frequency of switching between mania/hypomania and depression in bipolar disorder.  The current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines rapid cycling as four or more discrete mood episodes (manic/hypomanic and depressive) within the space of a year, which would be the equivalent of two full cycles through mania/hypomania and depression.  Rapid cycling is not its own diagnosis, and someone with bipolar disorder may have different frequencies of episodes at different times in their ives.

According to a paper by Papadimitriou and colleagues, 10-30% of people with bipolar disorder experience rapid cycling at some point, and 70-90% of those who experience rapid cycling are women.  Bipolar II disorder (involving episodes of hypomania and depression) is the diagnosis in which people are most likely to experience rapid cycling at some point, particularly when starting with a depressive episode.  People who were diagnosed with cyclothymia before developing bipolar disorder were also more likely to experience rapid cycling.

Rapid cycling is the only such term that appears in the DSM, but sometimes the terms ultra rapid cycling and ultradian (ultra ultra rapid) cycling are used to describe more frequent mood episodes.  Definitions may vary depending on who’s talking about it, but typically ultra rapid cycling is defined a mania <-> depression cycle within a  48-72 hour period.  Ultra ultra rapid cycling, often called ultradian cycling, involves a full cycle occurring within a 24 hour period.

Since full, discrete mood episodes (manic, hypomanic, and/or depressive) are required to make a diagnosis of bipolar disorder, when talking about ultra rapid cycling it becomes worth distinguishing between cycles and episodes.  In the DSM it is mood episodes, not cycles, that are used to determine whether or not bipolar disorder is the appropriate diagnosis.  The following definitions appeared in a paper in the Journal of Child and Adolescent Psychopharmacology:

“(1) Episodes will be defined by (a) the duration from onset to offset of a period of at least 2 weeks in length during which only one mood state persists or (b) the duration from onset to offset of a period of ultrarapid or ultradian cycling for at least 2 weeks. (2) Cycles will be defined by mood switches occurring daily or every few days during an episode.”

A review paper in Psychiatry Research mentions a study that found switches to manic-associated moods were more likely to happen during the day, while switches to depressed mood were more likely to happen at night.  However, there’s little research on this specific topic.  In general, much of the published research on ultra rapid/ultradian cycling has taken the form of clinical case reports, which aren’t considered a strong level of evidence as far as research goes, so it becomes difficult to draw reasonable conclusions..

A critical opinion published in Current Psychiatry argued that the constructs of ultra rapid and ultradian cycling have not been properly validated, and they may end up being misused to describe mood lability specifically rather than the full constellation of symptoms associated with a mood episode, or they may be used inappropriately to describe the variability that can occur within a mixed episode.  This supports the status quo DSM-5, which makes no reference to ultra rapid or ultradian cycling.

One diagnostic factor that may complicate things is the presence of co-occurring borderline personality disorder.  The affective instability symptoms of BPD tends to be a better fit for the “mood swings” descriptor that’s often thought to be associated with bipolar disorder.  Ultra rapid cycling has certainly been observed in people with bipolar who do not have BPD, but it’s one of the many factors that should be considered in a thorough diagnostic assessment process.  A BPD diagnosis requires multiple other symptoms in addition to mood lability.  There doesn’t appear to be any clear research to show whether ultra rapid cycle occurs only on a short-term basis or continues longer-term.  If it does only occur over a fairly short period of time then that would likely be an indicator that it’s not stemming from BPD, since BPD symptoms tend to be more consistent over time.  It’s also worth noting that mood lability does not necessarily represent a symptom of illness.

It’s not clear that any particular medications for bipolar disorder are any more effective than others when it comes to periods of ultra rapid cycling.  There is some possibility that antidepressant use may not be the best choice, but nothing clear enough to produce any actual treatment recommendations.  Then again, the evidence to support antidepressant use in bipolar disorder is sketchy to begin with.

While rapid cycling is clearly defined in the DSM as a specifier for bipolar disorder, ultra rapid and ultradian aren’t clearly defined, and the limited research on the topic means a limited understanding of the phenomenon.  It’s definitely an area where more research would be helpful.

If you have bipolar disorder, have you experienced rapid, ultra rapid, or ultradian cycling?

You can find the rest of my What Is series here.

Sources:

  • Goldberg, J. (2011). Ultra-rapid cycling bipolar disorder: A critical lookCurrent Psychiatry, 10(12), 42-55.
  • Papadimitrious, G.N. (2005). Rapid cycling bipolar disorder: Biology and pathogenesisInternational Journal of Neuropsychopharmacology, 8(2), 281-292.
  • Tillman, R., & Geller, B. (2004). Definitions of rapid, ultrarapid, and ultradian cycling and of episode duration in pediatric and adult bipolar disorders: A proposal to distinguish episodes from cycles. Journal of Child and Adolescent Psychopharmacology, 13(3).
  • Wilk, K., & Hegerl, U. (2010). Time of mood switches in ultra-rapid cycling disorder: A brief review. Psychiatry Research, 180(1), 1-4.

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33 thoughts on “What is… ultra rapid cycling

  1. BeckiesMentalMess.wordpress.com says:

    After reading this, I think I’m more confused over my initial diagnoses. Initially, when first in the hospital I was diagnosed with bipolar 2, a couple of years ago, It was determined that I had bipolar 1. It was never suggested that I had symptoms of BPD.
    The last depressive cycle I had between the months of Sept through Dec 2018, was horrendous. Obviously lasting more than a 24-72 hour period.
    What I am experiencing now is far different than that period, (maybe because of the medication) I have no idea. However, the highs and lows are within the time frame of 24-72 hours.
    Am I making any sense at all?
    I feel as if I’m battling every day to maintain being functional without lying in my bed all day. I truly push myself. And, this is still happening while I’m all this medication. I simply don’t understand why I am fluctuating again. It all seems to soon to have to fight through this again.

    • ashleyleia says:

      The biggest difference between bipolar I and II is whether the highs have gotten as high as mania or just hypomania. BPD is an entirely different diagnosis, but sometimes there’s confusion since people with BPD have rapid shifts in mood.
      Regardless, super frustrating that you’re going through this again when it’s been so little time since the last really low period.

      • BeckiesMentalMess.wordpress.com says:

        It’s as if my lows are what I’m fighting the most. That depressive cycle. I am functioning, but it’s exhausting.
        As far as the highs are concerned, I think (personally) I fall under hypomania more than mania.
        I see my psychiatrist in two weeks, thank goodness.

  2. Barb says:

    I don’t really know or rather, can’t remember if I’ve been through rapid cycling or not. What I do know is that the term was thrown around by my psychiatrist 10 years ago, which suggests that i experienced rapid cycling, if not ultra rapid or ultradian cycling.

  3. Clive says:

    This is very interesting, I’m also confused to what type I am. They just diagnosed me as bipolar, but I have rapid cycles, but more hypomanic than depressive. That’s what led me to think it maybe cyclothymia? because over the last year or so, I seem to have milder rapid cycles (more hypomanic) on a daily basis.These cycles are mild enough to manage, so I suppose I’m quite lucky really.

    • ashleyleia says:

      Rapid cycling isn’t a separate diagnosis, it’s just a specifier for a bipolar diagnosis. Cyclothymia is a distinct diagnosis from bipolar because it doesn’t reach the intensity of depression or hypomania.

      • Clive says:

        That’s what made me think it was cyclothymia, as it’s been much milder recently. I don’t know if someone can go from one type of bipolar to another? But I think that sometimes doctors are far to quick to diagnosis someone with whatever type of bipolar, before they fully know the person and their background.

  4. Melanie B Cee says:

    I have been diagnosed with Bipolar II, but my current therapist doesn’t believe it. However she does believe I’ve got symptoms of BPD (mild and from exposure to my parent who had that illness). Now from your excellent post, and like Beckie, I’m confused. Because although my depression is far more severe than what is described in ultra rapid cycling and I’m reassured I don’t have that, nor the ultra ultra cycling; I do experience the very mild forms of mania … the impulsive behavior, the ill managed spending, and mood swings that are now being attributed to BPD. I have to wonder if the psychiatric medicine professionals have a diagnosis for people like me because they seem to throw terms and illnesses around like so much confetti. I get that it’s hard to do their job and so much is being learned, even daily, about mental illness, that it may be hard to keep up.

  5. Savannah Williamson says:

    I loved this. Very informative. I have bipolar disorder and I definitely do experience mania followed by depression within one day, most days actually. The mania is probably due to my morning coffee and the depression sets in when I crash off the coffee. My un-caffeinated state is usually depression and I’ve got a major caffeine addiction going on. I drink absurd amounts of coffee and I’m worried about my health honestly. I’m like desperate to escape depression and I drink coffee like its a drug.

  6. Meg says:

    Wow!! That is a freaky good blog post. So informative!! It caused me to realize a lot, especially regarding bipolar and borderline.

    Yes, in high school, one psychiatrist postulated that I had bipolar with incredibly rapid swings (as in, several times a day). Adding in what you said about being borderline is so spot-on. I’m not borderline (I don’t think), but I was in high school (as a developmental phase, I think, since the personality isn’t formed yet in high school). And I’d become convinced several times a day that no one liked me, and I’d burst into tears, and then I’d be euphoric, and then I’d cry again, and it was really wild.

    As an adult with bipolar, I don’t think it’s ever been an issue. It reminds me a little of being on my period, though!!

    Great post!!

    • ashleyleia says:

      Yeah I think sometimes mood swings sometimes end up getting mislabelled, because lability in mood in and of itself isn’t necessarily indicative of illness.

      • Meg says:

        That is so interesting. So, mood swings could = hormones or circumstance or a personality issue, whereas bipolar is more about large chunks of time as manic/hypomanic and then depressed?

        • ashleyleia says:

          A manic, hypomanic, or depressive episode requires that multiple symptom criteria be met, including a certain length of time that symptoms are experienced. Mood lability isn’t actually a symptom criteria for bipolar.

  7. Casey Elizabeth Dennis says:

    I have rapid cycling too, when I’m not on medication. I have mood swings during the day but my therapist thinks it’s from PTSD. And those with bipolar are more likely to be involved in trauma. It could be possible that sometimes you’re triggered by things throughout the day. Just my thoughts.

  8. Sebastian says:

    Before I got the right medication I was ultra ultra rapid cycling. I had swings every two hours, and on a particular day every 30 minutes. Sadly the first medication I got made everything worse, I ended up being manic for a full week before finally I stopped taking them. I got new meds and the cycling stopped, but I came so depressed I wanted to die. It took two months for the mood stabilizers to kick in and that’s when I got out of my depression. But because I have severe anxiety I need to take antidepressants. I’m know well adjusted and working again. But I’d never want to experience this horror again. It was so stressful and made me so tired I really wished I’d die. Fortunately my psychiatrist was very helpful and tried a lot to help me.

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