Thinking Twice About Ultra-Rapid Cycling Bipolar Disorder

Bipolar disorders present a high rate of misdiagnosis issues (e.g., Rakofsky et al., 2015; Shen et al., 2018; McIntyre et al., 2022). This has a lot to do with poor differential diagnosis practice and a misconception, even amongst some clinicians, that, as noted in the post "Coming to Terms," any pervasive moodiness is synonymous with "bipolar." It is commonly misdiagnosed as unipolar major depression (e.g., Nasrallah, 2015; Stiles et al., 2018; McIntyre et al., 2022) or over-diagnosed (e.g., Ghouse et al., 2013; Morgan & Zimmerman, 2014; Cogen et al., 2021; Doyen, 2021) when personality, trauma, or other items encourage the rollercoasters of moodiness.

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Within bipolar disorder diagnoses, it is not uncommon to witness the specifier, "with rapid cycling," a Diagnostic and Statistical Manual (DSM) and International Classification of Disease (ICD)-sanctioned distinction. There is also the proposed ultra, or ultra-ultra (ultradian) rapid cycling specifier that has gained attention over the years, which throws another wrench into the misdiagnosis tendency.

As detailed below, this latter notation should raise further diagnostic accuracy suspicion because there is inherent, vacillating moodiness in many conditions, coupled with the fact that bipolar disorder is a popular diagnosis, albeit perpetually misunderstood, lending itself to application by those inclined to impulsive diagnosing based off of one chief symptom.

Rapid Cycling Defined

The rapid cycling specifier is applied only to bipolar types 1 and 2 to define four or more distinct mood episodes (major depression, manic, hypomanic, or mixed) within one year (APA, 2013). It's been estimated that such cycling is present in only 10-20% of people with bipolar types 1 and 2 (e.g., Valenti et al., 2015; Bourla et al., 2022), which have an occurrence rate of 0.4-2 percent of the general population (e.g., Clemente et al., 2015; Rowand & Marwaha 2019). Thus, readers can easily see that witnessing basic rapid cycling bipolar disorders is a rare phenomenon. As an aside, interestingly, Carvalho et al. (2014) noted that it seems rapid cycling is correlated to being triggered by antidepressants and hypothyroidism in many.

Further, it is important to note that rapid cycling is markedly different from cyclothymia, a "soft bipolar" condition. Cyclothymia, by nature, is the years-long, chronic cycling of sub-major depressive and sub-hypomanic symptoms approximately every few days without disruption; the dysthymia of bipolar disorders, if you will.

Ultra-rapid and ultradian cycling has never been included in the DSM or the ICD as a bipolar disorder specifier and continues to be a topic of debate (e.g., Swann et al., 2013; Shirazi et al., 2017),

Critical Thinking About Ultra-Rapid Cycling

Anyone who has worked with bipolar disorder knows that an expansive mood/affect is a hallmark of mania. The patient's affective state is frequently marked by an oscillation of dysphoric/depressed, irritable/angry, and bright/jocular affects by the minute or hour. Given this is such an obvious trait and that manic people aren't necessarily always exhibiting restlessness, pressured/disorganized speech, etc., to indicate the "full manic package," the markedly oscillating and easily-observed mood/affect may be taken as evidence of distinctly altering mood states ("episodes") and thus lead to assumptions of ultra-rapid/ultradian cycling if careful diagnostic questioning and observation are not applied.

Next, to be considered rapid cycling, as noted previously, there must be distinct episodes, and mood episodes, by definition, are days to weeks long. However, ultra-rapid and ultradian cycles are described as mood alteration by as little as a day or amongst the hours, hardly meeting the criteria for what's considered an episode. Further, without the most scrutinizing observation, does it not seem nearly impossible to evaluate if someone met all the criteria of a mood episode within hours, or if it may be better accounted for by the confusing, jumbled mass of fully mixed episodes?

Estimates of prevalence vary, but up to 40 percent (i.e., Fagiolini et al., 2015) of people with bipolar disorder are prone to mixed episodes. This means that the patient experiences at least a few symptoms of depression during mania or hypomania/vice-versa. Further, like the proposed ultradian bipolar disorder subtype, mixed episodes tend to be long-lasting and severe, rendering a poorer prognosis.

Additionally, clouding the matter, it is possible that one of the affective states in a mixed episode could be periodically more prevalent during the mixed period, ostensibly suggesting distinct mood states. With such things in mind, Swann et al. (2013) noted that mixed states present challenges to ultra/ultradian cycling concept, as it's possible the proposed ultra/ultradian bipolar disorder is really a nuanced mixed episode.

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Overall, the above raises the further question if it should be considered a distinct form of bipolar disorder if one or another affective state in a mixed episode is sufficiently demarcated in rapid form. Further deducing, is ultra-rapid/ultradian cycling just a different term for people who primarily experience long, mixed episodes?

All of this said, is not to suggest that ultra-rapid and ultradian cycling may not be discovered to indeed be a distinctive diagnostic niche within bipolar disorder. However, there is clearly an inordinate amount of room for diagnostic error within the affective disorder category alone, never mind the ultra-rapid cycling chameleons in other diagnostic categories.

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Rapid Cycling Chameleons

Consider that people with some personality disorders, especially borderline and histrionic, have characteristically-rapidly shifting/reactive moods on a daily basis. Those with PTSD may also exhibit reactive moodiness. All three are prone to major depressive episodes. These rapidly-shifting moods superimposed on a depressed background can, at first glance, suggest rapid cycling "bipolar disorder" to those prone to kneejerk diagnosing based on one chief symptom.

Differential Diagnosis Tips

Take time to cover the bases of the diagnostic process. It is erroneous and dangerous to subscribe to the idea that laser-sharp accurate diagnosis isn't important because ultimately, "we treat symptoms, not disorders." Many disorders share symptoms, but that doesn't mean they're treated alike.

To illustrate, bipolar disorder and borderline personality are known for moodiness, and in 20+ years of practice and supervising, I can say it's not unusual for a one-size-fits-all "coping skills and medication" approach to be adopted by people complaining of moodiness. For more than tenuous stability, bipolar disorders, at minimum, require psychiatry and a focus in therapy on maintaining good sleep patterns and keeping stress at bay so as not to kindle mania. Borderline personality treatment requires cultivating more constructive interpersonal relating through changing the problematic core schema, which drives their tendency to reactive moodiness.

And therein lies a key differential component: assessing if regular, significant mood changes are correlated to events, which would indicate a personality trait. If so, investigating for evidence of borderline, histrionic, or other cluster B personalities is important. It is also essential to evaluate if the person has a severe trauma history that would lend itself to regular, altering angry and anxious reactions that may be superimposed on depression, ostensibly appearing as "rapid cycling."

Finally, some "tells" that rollercoasters of moodiness may indeed be bipolar disorder include:

• There seem to be no particular activating events; the moodiness endogenously blossoms.
• The presence of psychotic features, especially grandiose delusions like having superpowers or holding positions of importance, and auditory hallucinations.
• A clear family history of bipolar disorder based on relatives' descriptions of clearly alternating manic/hypomanic/mixed/depressed episodes, record review, and collateral contact with providers; not taking "I'm bipolar" or "a doctor once told me I'm bipolar" at face value.
• The mood shifting happens in the absence of substance abuse and is not influenced by any prescription medications, especially antidepressants.
• There is no medical complication at hand, such as an endocrinological disease or organic damage.

Disclaimer: The material provided in this post is for informational purposes only and not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care from an individual's provider or formal supervision if you’re a practitioner or student.