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Ask the Mental Health Expert Archives 2001-2004

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Bipolar Ultra Rapid Cycling

Q. Do you have any information about bipolar ultra rapid cycling?

A. There is only limited information on so-called ultra-rapid cycling, and there is no universally accepted definition of this term. (The term rapid-cycling does have a specific definition: the presence of four or more major mood episodes (depression or mania) within a given year). The conventional upper limit for cycling in bipolar disorder is usually a 48-hour cycle; that is, no more than one manic and one depressive episode within a two day period. When mood swings appear to be more frequent than that, many clinicians begin to doubt the diagnosis of bipolar disorder, and wonder, for example, if the individual is showing features of a personality disorder, such as Borderline Personality Disorder. (Borderline individuals may have fluctuations in their mood from hour to hour, or even minute to minute, depending mainly on various interpersonal disturbances).

On the other hand, some data suggest that a small group of bipolar patients may cycle much more rapidly than every 48 hours. For example, Kramlinger et al (Br J Psychiatry 1996 Mar;168(3):314-23) reported on five bipolar patients who underwent intensive in-patient psychiatric evaluation, including prospective evaluation of daily mood by self and blinded observers, as well as motor activity recording. They found that some of the subjects showed "clinically robust mood shifts that occur at frequencies faster than once per 24 hours."

Ultra-rapid or ultradian (less than 24 hour) cycling has also been reported in prepubertal and early adolescent bipolar patients (Geller et al, J Affect Disord 1998 Nov;51(2):81-91). Some case reports suggest that the medications valproate and nimodipine may be helpful in ultra-rapid cyclers (Lepkifker et al, Clin Neuropharmacol 1995 Feb;18(1):72-5; Pazzaglia et al, Psychiatry Res 1993 Dec;49(3):257-72). Not every individual with ultra-rapid cycling has true bipolar disorder, however. For example, Zwil et al report on a patient with a severe and disabling ultra-rapidly cycling mood disorder following a mild head injury (Brain Inj 1993 Mar-Apr;7(2):147-52). The patient showed diffuse cerebral injury with a predominance of left frontotemporal findings. Clearly, we have much to learn about ultra-rapid cyclers-regarding both the causes and treatment of their condition.

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August 2001

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