Rapid Cycling Bipolar Disorder

Bipolar disorder, also known as manic-depressive disorder, is a condition that affects nearly 4.4% of U.S. adults.  It is a complex mental health disorder that causes abrupt, inexplicable mood swings that can include emotional highs (mania or hypomania) and lows (depression). As detailed in a previous blog post, bipolar disorder is mainly recognized by its two types, Bipolar I and Bipolar II.  Bipolar I patients experience more extreme manic episodes and may not experience any depressive episodes.  On the other hand, Bipolar II patients experience hypomania (a less severe form of mania) and depressive episodes as well.  Within the spectrum of different symptoms and manifestations of bipolar disorder is a lesser known type of bipolar disorder, known as rapid cycling bipolar disorder.  This form of bipolar disorder is particularly marked by frequent mood shifts that complicate treatment and disrupt the lives of those who are diagnosed.  In this blog, we will detail the intricacies of rapid cycling bipolar disorder, including its symptoms, causes, and other insights.

What is rapid cycling bipolar disorder?

Individuals who are diagnosed with bipolar disorder either experience the ‘highs’ that come along with mania or hypomania, the ‘lows’ that are accompanied by depression, or both.  For a person to be diagnosed with bipolar disorder, they have to experience a hypomanic or manic episode as well as multiple additional episodes of mania, hypomania, or depression.  In addition, the symptoms that patients feel must represent a significant deferment from their typical, normal behavior. It is not just experiencing normal mood swings, but rather an intense mood shift that can affect everyday interactions and relationships.  People who are diagnosed with bipolar disorder usually experience 1-2 episodes in a year.

The concept of ‘rapid cycling’ to describe bipolar disorder was first introduced during the 1970s and is considered to be a course specifier in the DSM-5. In other words, rapid cycling is not necessarily a diagnosis within itself, but rather describes the course of bipolar disorder.  Health professionals began to use the term in order to describe patients that experience 4 or more episodes of mania, hypomania, depressive, or mixed-state episodes in a 12-month period.¹  The change in mood can happen very quickly and take place over a few days or even across the span of a few hours.  Episodes for people who have rapid cycling bipolar disorder can experience the episodes in any combination or sequence, and such rapid shifts from one mood state to another can be overwhelming. It can also be difficult to manage rapid cycling because although the name suggests a pattern of episodes, patients are unable to anticipate what type of episodes are coming next.  If a person experiences 4 or more episodes of mood shifts within a single month, it is known as ultra-rapid cycling, and if the rapid cycling occurs within 24 hours, it is known as ultradian rapid cycling.²

According to a meta-analysis on 20 clinical studies, researchers determined that patients who experience bipolar disorder with rapid cycling are 7x more likely to experience full-duration manic and hypomanic episodes, and 2x more likely to experience depressive episodes compared to bipolar patients who do not experience rapid cycling.  In the same meta-analysis, the research revealed that the overall prevalence of rapid cycling is about 16.3%, and important to note is that experiencing rapid cycling is not a static experience.³  In fact, nearly half of all individuals who have bipolar disorder may develop rapid cycling symptoms at some point in their life.  Rapid cycling is commonly a temporary occurrence, but a smaller group of individuals do experience it continuously.^2,3  Research also suggests that females and individuals with Bipolar II disorder are more likely to experience rapid cycling than other groups. Another feature of rapid cycling is that increased episode frequency is associated with manic and hypomanic episodes, while the number of depressive episodes remains fairly constant regardless of the number of episodes.³

 

Symptoms

The symptoms of rapid cycling bipolar disorder include the entire range of bipolar symptoms, but they occur with greater frequency. These symptoms can include:⁴

Manic Episodes

1. • Appearing very high or up, elated and very irritable
   • Jumpy, wired, hyperactive or more active than usual
   • Having a decreased need for sleep
   • Talking very quickly about a number of different things, also called a “flight of ideas”
   • Uncontrollable, racing thoughts
   • Restlessness, feeling able to accomplish a lot at once without tiring
   • High appetite for food, drinking, sex, pleasurable activities
   • Self-important, powerful, talented

Hypomanic Episodes

1. • Similar to manic episodes to an extent, not nearly as severe
   • Not severe enough to cause significant impairment in social/occupational functioning

Depressive Episodes

1. • Sad, down, anxious feelings
   • Restless and low energy
   • Difficulties in falling asleep, waking up earlier than usual, or sleeping excessively
   • Slowed speech, cannot find words to say anything, forgetful
   • Issues with concentrating, unable to make decisions
   • Unable to complete simple tasks
   • Lacking interest in activities (even ones that they typically enjoy)
   • Hopeless, worthless, thinks about suicide or death

Mixed Features Episodes

1. • Simultaneous symptoms of both mania/hypomania and depression in a singular episode
   • Combination of high energy and depressive thoughts (feeling sad or hopeless while also feeling super energized)

 

Who is most likely to develop rapid cycling bipolar disorder?

Though the exact cause of rapid cycling bipolar disorder is not completely understood, research suggests that there are a combination of genetic, environmental, and biological factors that influence who may be more likely to develop it.  According to a study done on 539 patients with bipolar disorder, researchers determined that patients with rapid cycling bipolar disorder typically had an earlier age at onset, a longer duration of illness, and a longer period between first symptoms and first medication treatment compared to bipolar patients who did not have rapid cycling.  In addition, this study found that rapid cycling is associated with a history of mixed features episodes, treatment with antidepressants, history or substance-induced episodes, anxiety disorder, childhood physical or sexual abuse, and parental history of drug abuse.³   

While bipolar disorder can affect individuals equally regardless of gender,  women are more likely to develop rapid cycling bipolar disorder compared to men.  In addition, having a family history of bipolar disorder or specific genetic markers can increase the risk for developing rapid cycling.²

Possible Causes

There are several theories that explore the causes of rapid cycling in bipolar disorder, and why some people may develop it.

 

The Kindling Theory

Proposed in 1992, the Kindling theory suggests that the more mood episodes a person experiences, the more they are likely to suffer from increased sensitivity and a lowered threshold for subsequent episodes.⁵ While the early, or initial, episodes of bipolar disorder are more likely to be triggered by anticipated or actual major life stressors, episodes become less and less related to a person’s original stressors and instead become more autonomous over time. For example, stressful life events like the loss of a parent or severe financial stress can become potential triggers for an individual. As time goes on, however, just the stress associated with the event can cause a mood episode. In the context of rapid cycling bipolar disorder, the Kindling theory proposes that each manic, hypomanic, or depressive episode makes the brain more susceptible to future episodes, thereby quickening the cycle frequency. ^2,5

Hypothyroidism

Hypothyroidism, a condition in which the thyroid gland is underactive and produces deficient thyroid hormones, has been linked to mood disorders. Thyroid hormones function to help regulate metabolism and brain function, and their deficiency can lead to symptoms like fatigue and depression. In a study of 30 patients, research found that Grade I hypothyroidism may be a risk for rapid cycling.⁶ In rapid cycling bipolar disorder, hypothyroidism disrupts hormonal levels and even small changes to thyroid levels can lead to severe mood shifts, making it difficult to achieve mood stability. Research has shown that bipolar patients with rapid cycling respond well when treated with thyroid hormone.²

Circadian Rhythms

Some researchers believe that rapid cycling bipolar disorder may be a result of when a person is ‘not in sync’ with their normal functioning circadian rhythm.² All individuals function on a 24-hour sleep-wake cycle, and this rhythm regulates various physiological processes within the body. It is known that maintaining a good sleep routine can help stabilize mood and soothe some of the symptoms that are associated with bipolar disorder as a whole.

Treatments

Since rapid cycling is a course specifier of bipolar disorder, and not its own diagnosis, it can be difficult to treat and even anticipate. Individuals who experience rapid cycling may benefit from practices such as consistent mood tracking, psychotherapy, and a personalized medication plan.^2,4

• Mood tracking: Bipolar episodes can be difficult to distinguish, as many patients may not notice when they are in certain mood states. This can complicate one’s ability to even know if they are experiencing rapid cycling.  Sometimes, when bipolar patients experience manic or hypomanic episodes, they may crack it up to simply being in an unusually good mood.  Keeping track of one’s mood may help a person stay on top of any changes to their moods, and also helps one notice what things may be triggering stress.
• Psychotherapy and medication plans: Talk therapy can aid individuals in identifying what emotions, thoughts, and moods they are experiencing. It provides support and guidance, while also helping patients keep to a treatment plan without feeling overwhelmed.  Quickly shifting emotions can feel unbearable to manage, but it is possible.  In conjunction with psychotherapy, patients can work with a psychiatrist to determine which mood stabilizers and atypical antipsychotics may help control symptoms. Mood stabilizers like valproate or lithium can help reduce and manage mood episodes, and other medications can be used to treat the anxiety or depressive associated with bipolar disorder.