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.