Rapid Cycling Bipolar Disorder: Symptoms, Characteristics, Risk & Treatments

Jun 5, 20246 min
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According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), Bipolar and Related Disorders are characterized by extreme mood swings from euphoric highs (mania) to depressive lows. These mood swings cause abrupt shifts in energy levels, attention, motivation, and behavior of the affected individual. A person may move from undertaking a frenzy of activities to a state of low energy and complete loss of interest. Understandably, this may lead to a lot of challenges in navigating daily life, home, work, and interpersonal relationships.  

What is Rapid Cycling Bipolar Disorder?

Rapid Cycling Bipolar Disorder serves as a course specifier for Bipolar and Related Disorders. It means that this is one of the ways bipolar symptoms may show up over a period of time. An individual with Rapid Cycling Bipolar Disorder experiences more frequent fluctuations in mood than individuals with Bipolar Disorder with no Rapid Cycling. In the next section, we talk about the symptoms of Rapid Cycling Bipolar Disorder in detail.   

What are the symptoms of Rapid Cycling Bipolar Disorder?

For a diagnosis of Rapid Cycling Bipolar Disorder, individuals must meet the diagnostic criteria for one of the Bipolar and related disorders  (Bipolar I Disorder, Bipolar II Disorder, or Cyclothymic Disorder). 

Additionally, the following criteria must be fulfilled:

1.Frequency of Mood Episodes:

Experiencing a minimum of four distinct mood episodes (manic, hypomanic, depressive, or mixed) within a year. These episodes should fully meet the criteria for each mood state and be separated by periods of partial or complete remission lasting at least two months, or by a shift to the opposite mood state (for example, a depressive episode is followed by a manic episode).

2.Episodic Course:

The rapid cycling pattern should not be better explained by another mental disorder (such as schizophrenia spectrum disorders or other psychotic conditions). While mood fluctuations may appear similar on the surface (e.g., stress, anxiety), the cause of it may vary. It is important to distinguish the causal factors with the help of a clinical psychologist to get appropriate treatment.  

These criteria define Rapid Cycling Bipolar Disorder, highlighting the frequent and distinct mood fluctuations over a relatively brief period, which can significantly impact the individual's functioning and quality of life.

Since rapid cycling is a course specifier for Bipolar and Related Disorders, it means that all bipolar patients are potentially at risk for rapid cycling during the course of their illness. There is debate regarding whether rapid cycling is a temporary occurrence or it could be more appropriately classified as a subtype of bipolar disorder (Schneck, 2006)

What are the features of Rapid Cycling Bipolar Disorder?

While the term "rapid cycling" suggests that a patient oscillates between episodes of depression and mania, individuals with Rapid Cycling Bipolar Disorder often experience more depressive episodes than manic episodes. The depressive episodes are found to be more severe compared to those without rapid cycling. These depressive episodes also tend to be more difficult to treat compared to those in patients without rapid cycling.

There is a high risk of misdiagnosis when the onset of Rapid Cycling Bipolar Disorder is marked by a depressive episode. The clinician may see it as a case of a Major Depressive episode and treat it accordingly. However, research suggests that the use of antidepressants can worsen rapid cycling, although the exact cause of rapid cycling remains poorly understood. Therefore, it is essential to monitor symptoms over time and select treatment options accordingly. 

What are the risk factors associated with Rapid Cycling Bipolar Disorder?

The onset of a mood episode is usually triggered by multiple factors leading to affective instability. Some of the risk factors associated with Rapid Cycling Bipolar Disorder are discussed below. 

It is important to understand that the mere presence of these factors does not mean that an individual is experiencing Rapid Cycling Bipolar Disorder. It is a comprehensive evaluation made by a clinical psychologist or a psychiatrist based on multiple factors like the nature and severity of symptoms, level of distress, etc. 

1.Biological Factors:

The onset of mood episodes at an early age is associated with Rapid Cycling Bipolar Disorder. There's some indication that Bipolar II disorder is more likely to involve rapid cycling due to the greater prevalence of depressive episodes.

Additionally, female gender has been linked to rapid cycling in bipolar disorder. However, these findings require stronger empirical evidence to solidify their validity.

The presence of other medical conditions and substance use can also elevate the risk of developing Rapid Cycling Bipolar Disorder.

2.Psychosocial stressors: 

The presence of stressful events can understandably exacerbate mood fluctuations. Often, individuals experience stress when they are unable to manage the demands of the task at hand. Certain life events experiencing a transition, change in routine, loss, or grief can also cause a significant amount of stress to the individual. 

What is the treatment for Rapid Cycling Bipolar Disorder?

The mood alternations in Rapid Cycling Bipolar Disorder are caused by the interaction of multiple biological and psychosocial factors. Hence, an integrated treatment including medications and psychotherapy works best. 

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) is a comprehensive outpatient study aimed at identifying the most effective treatments, either individually or in combination, for managing episodes of depression and mania, as well as preventing recurrent episodes in individuals with bipolar disorder.

The management of rapid cycling of mood episodes within STEP-BD begins with confirming that the patient is experiencing active cycling and not an episode of Major Depressive Disorder.

Once established, the patient proceeds through a three-step pathway for rapid cycling management.

1.Identifying and Managing Triggers: 

Any potential triggers that exacerbate rapid cycling, such as antidepressants, stimulants, caffeine, sympathomimetics, or steroids, are identified. The clinician and the patient collaboratively discuss the strategies to manage triggers and alternative actions to address underlying needs. 

For example, what strategies can a patient employ to deal with daily tasks without the use of antidepressants?

It is also important to identify and manage psychosocial factors that may trigger rapid cycling bipolar disorder, particularly the psychosocial activities that disrupt sleep-wake cycles, such as irregular work shifts and interpersonal conflicts.

2.Symptom Management: 

During treatment, any underlying medical conditions or concurrent substance abuse issues are identified and managed by clinicians. Instead of abruptly stopping antidepressants, there is gradual reduction of the dosage, typically by 20% to 30% per month.

Following this adjustment, mood-stabilizing medications such as lithium or lamotrigine are typically introduced to help stabilize rapid mood-cycling symptoms. Patients' responses to these medications are closely monitored over several months. If cycling persists despite these initial treatments, second-line options such as atypical antipsychotics may be considered.

Experimental treatments for rapid cycling bipolar disorder are reserved for cases where more conventional treatments have been unsuccessful. These alternative approaches are explored only after thorough evaluation and consideration of the patient's individual circumstances.

3.Psychotherapy:

Psychotherapy can be incredibly beneficial for individuals dealing with stressful life events, offering opportunities to process these experiences, gain insights, and develop skills to navigate challenges effectively. Therapeutic approaches such as Interpersonal & Social Rhythm Therapy focus on establishing a daily routine, aiding in the restoration of circadian rhythms, stabilizing daily behaviors, and fostering consistency, and can lead to improvements in mood and overall functioning (Haynes et al., 2016).

Additionally, interventions like couples and family therapies can assist patients in identifying and addressing interpersonal struggles and strengthening familial understanding and support, which in turn can enhance treatment outcomes.

If you suspect that you may be experiencing symptoms of Rapid Cycling Bipolar Disorder, it's important to remember that you're not alone, and support is available. Consider reaching out to a clinical psychologist to get the help you deserve. If you're unsure where to begin your mental health journey, Mave Health’s Therapy Club can offer a starting point. As one of the largest mental health platforms in India, we provide access to qualified mental health practitioners across various states, catering to diverse mental health needs.

Assessment of Treatment Response 

Assessing treatment response in Rapid Cycling Bipolar Disorder requires monitoring symptoms for at least four months or three cycle lengths. The mood charts can serve as valuable tools for tracking the course of illness and evaluating the effectiveness of interventions. 

It is important that conclusions about treatment efficacy are made only after tracking symptoms consistently for multiple episodes. A single improvement or recurrence does not necessarily determine success or failure. A higher remission rate and decreased intensity of symptoms are some indicators of effective treatment. 

The clinicians must balance the immediate needs of the patient, particularly when they are in a depressive episode with long-term stability. For example, avoiding the use of antidepressants to prevent destabilization over the course of the illness.

In Conclusion  

Treating rapid cycling poses significant challenges, especially given the severity of depressive episodes compared to manic ones. Research findings warrant caution in using antidepressants due to their potential to worsen rapid cycling. Typically, combination therapy involving established mood stabilizers is preferred, reserving experimental treatments for treatment-resistant cases of persistent cycling. Psychotherapy is invaluable for enhancing medication adherence, alleviating psychosocial stress, and crafting relapse prevention strategies.

In essence, managing rapid cycling bipolar disorder requires a comprehensive approach to treatment that integrates pharmacological interventions, psychotherapy, and cautious monitoring of symptoms. This holistic strategy is vital for improving long-term outcomes and enhancing the quality of life for affected individuals.

REFERENCES 

  1. American Psychiatric Association, D. S. M. T. F., & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (Vol. 5, No. 5). Washington, DC: American psychiatric association.
  2. Haynes, P. L., Gengler, D., & Kelly, M. (2016). Social rhythm therapies for mood disorders: an update. Current psychiatry reports18, 1-8.
  3. National Institute for Mental Health (n.d.). Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).
  4. Schneck, C. D. (2006). Treatment of rapid-cycling bipolar disorder. Journal of Clinical Psychiatry67, 22.
Author's Profile picture
Mave
Clinical Psychologist