In this series, I dig a little deeper into the meaning of psychological terms. This week, we’re looking at ultra rapid and ultradian cycling in bipolar disorder.
Before we get into that, let’s take it down a notch and consider rapid cycling, which describes 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 lives.
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.
Ultra rapid & ultradian cycling
Rapid cycling is the only such term that appears in the DSM, but sometimes the terms ultra rapid and ultra ultra rapid (ultradian) 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 as a mania–depression cycle within a 48-72 hour period. Ultra ultra rapid (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/ultradian cycling it becomes worth distinguishing between cycles and episodes. The DSM-5 uses mood episodes, not cycles, to determine whether 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.”
Debate within the research community
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. The authors expressed concerns that the terms may end up being misused to describe mood lability specifically rather than the full constellation of symptoms associated with a mood episode. Another concern was that 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.
Co-occurring BPD
One diagnostic factor that may complicate things is the presence of co-occurring borderline personality disorder (BPD). The affective instability symptoms of BPD can 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 on its own doesn’t necessarily represent a symptom of illness.
Management
It’s not clear that any particular medications for bipolar disorder are any more effective than others for ultra rapid cycling. 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 the what is… series in the Psychology Corner, and more about the treatment of bipolar in Psych Meds 101: Mood Stabilizers.
References
- Goldberg, J. (2011). Ultra-rapid cycling bipolar disorder: A critical look. Current Psychiatry, 10(12), 42-55.
- Papadimitrious, G.N. (2005). Rapid cycling bipolar disorder: Biology and pathogenesis. International 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.
Making Sense of Psychiatric Diagnosis aims to cut through the misunderstanding and stigma, drawing on the DSM-5 diagnostic criteria and guest narratives to present mental illness as it really is.
It’s available on Amazon and Google Play.
Ashley L. Peterson
BScPharm BSN MPN
Ashley is a former mental health nurse and pharmacist and the author of four books.
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.
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.
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.
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.
Oh interesting
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.
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.
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.
Cyclothymia isn’t a type of bipolar. It’s considered a separate diagnosis. I’ve you had an episode of depression or hypomania, then bipolar is the diagnosis.
I was always led to believe cyclothymia was a milder type of bipolar? Or have I been miss informed? this link is saying there’s actually several types?
In the DSM the diagnoses are separate. To be diagnosed with cyclothymia a person can’t ever have met the criteria for a manic, hypomanic, or depressive episode. That WebMD page is also a bit misleading in that mixed features isn’t its own diagnosis; it’s applied to a manic, hypomanic, or depressive episode.
It’s very misleading, I read so many different articles regarding bipolar, and how many types and variations of the condition. It actually could trigger an episode reading up on it! 😂👍
lol
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.
I don’t think I described it very well since I seem to have caused more confusion than anything! Ultra rapid cycling is a descriptor that gets tossed around but it’s not actually in the DSM. To have a diagnosis of bipolar, a person still needs to have met the criteria for mania/hypomania/depression.
Whatever type we all are, we are still all riding on the same crazy train! 😁👍
This is so informative!
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.
Hmm, that sounds really tough.
Yeah it’s okay. I was kind of thinking out loud there. Just realized I had an issue. It was kinda unrelated to the post. Sorry about that.
Hey that’s ok. And if caffeine is a way of self-medicating for depression that’s probably worth a closer look at.
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.
That makes sense that it’s sometimes quite a bit more complicated than just the effects of bipolar.
That was also suppose to be a response to Beckie’s comment but WordPress was fighting me. But I think most people have dual diagnoses but might not be aware of it.
Yeah for sure.
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.
I’m glad you were finally able to find medications that worked.
This resonates with me on so many levels. Diagnosed Bipolar 2 around 18, only went onto meds two years ago at 34 and absolutely life changing for the better. When I do have my episodes (mostly triggered when I am very stressed), my mood will flip from hypomania to depression at least four times a day. It is exhausting. I will be elated for overcoming the depression only for the depression to bring me down again. Repeat. Draining. By night I’m just solidly depressed and when I wake up again, well it is anyones guess. If it lasts longer than 7 days it is back to the psych to try and find balance again & going to try a psychologist now as well. This is a hard illness to deal with.
That sounds really tough. I’m glad at least the meds are helping.