Hard to define. Even harder to treat.

by John McManamy



One day this, a couple days that, a couple more days back to this ... back and forth back and forth. My boyfriend now, well, he can't handle me. ... Sometimes I feel like I will never be able to have a relationship because my feelings keep flip-flopping. Well, that's what is happening now. I think I have worn him out.

Nowhere is the DSM more out of touch with reality than in its criteria for rapid-cycling, this despite the fact that up to twenty percent of those with bipolar disorder may rapid-cycle. The DSMspecifies at least four episodes of mood disturbance over the last 12 months to at least two months in remission and back or by a switch from one pole to the other. Rapid-cycling can occur in patients with both bipolar I and bipolar II, as well as unipolar depression.

For an illness defined by its ups and downs, however, cycling in and out of four mood episodes a year seems perfectly normal and downright leisurely. True, four episodes a year is four episodes too many, particularly when just one represents a life-threatening situation, and especially if the episodes come on suddenly. But poor Anonymous has to contend with the emotional whiplash of lurching from one extreme to the other every couple of days.

Ironically, because the DSM requires a minimum of two weeks for a depressive episode, one week for a manic episode, and four days for a hypomanic episode, this unfortunate woman's condition is technically unrecognized as such by psychiatry.

In an article in the Fall 2003 Journal of Child and Adolescent Psychophramacology, Tillman and Geller describe the example of a bipolar child who cycles up and down twice a day for one year. "With the terminology currently in use," they report, "it is unclear whether this should be described as a single episode that had a duration of 365 days or as approximately 730 episodes ... each less than 24 hours in duration."

Unofficially, psychiatry recognizes ultrarapid cyclers (occurring every few days) and ultradian cycling (occurring during the course of a day). Unfortunately, there is virtually no data providing insight into clinical distinctions, much less treatment. We do know that rapid-cyclers are more difficult to treat and that they are particularly sensitive to mood triggers, from bad encounters at work or with family to medications side effects to being overstimulated to too much caffeine to losing a night's sleep.

But recovery is the last thing on your mind if you are experiencing your second major depression in a row or you are reeling from the disorienting whiplash from mania or hypomania to depression and back again in a matter of days. The phenomenon is “rapid-cycling,” which can be viewed as one outcome of kindling.

The DSM mandates a minimum of four episodes a year, spaced out by periods of remission. But a good many patients can go from up to down and back again within days. Technically, they have failed to meet the time minimum (two weeks for depression, seven days for mania, four days for hypomania) for an episode. The DSM gets around this problem by failing to acknowledge the situation.

Real-world psychiatry, nevertheless, recognizes those who experience “ultra-rapid” and “ultradian” cycling. Try to imagine the terror of lurching from one emotional extreme to another in the space of days or even hours.

Or, if your rapid-cycling proceeds at more of a DSM pace, try to imagine that sense of relief you experienced after emerging from a crushing three-month depression. Then, say, a month later, your luck runs out. The bottom falls out of you. Here we go again.

For a condition capable of so much distress, we know very little about it. A 2014 literature search conducted by a team of leading international researchers came up with just 119 relevant articles. In a review article they published in the June 2014 Journal of Clinical Psychiatry, among other things, the authors observed:



  1. Many more women than men experience rapid-cycling.
  2. The condition is fairly common, but not necessarily permanent.
  3. It is associated with a younger age of bipolar onset.
  4. Suicidality and alcohol and drug abuse are more common among those who rapid-cycle.
  5. There is an overlap with mixed states.
  6. There is a possible association with hypothyroidism.
  7. Antidepressant treatment may set off rapid-cycling, but further study evidence is needed.
  8. The prevailing view is that the condition is more associated with bipolar II, but other studies suggest a stronger association with bipolar I.




This is where readers would expect to shift gears into rapid-cycling in more depth, but there is a major problem. In the more than 16 years I have had this Website up, I have been aware of a crying need to have an in-depth article on the topic, but one is hard-pressed to report on what even the experts don't know. To those of you who rapid-cycle, psychiatry owes you an apology. They have let you down, left you in the dark. I wish I could give you more to go on, but what is on this page is the probably best you will find anywhere. It's not an accomplishment I take pride in.

If you are one of those who experience rapid-cycling, keep in mind that your immediate goal is to achieve stability, or at least learn to anticipate and adapt. A lot of people with bipolar—rapid-cycler or not—don’t seem to get going until well into the day. Then, in the evening, they may experience an energy surge that keeps them fully engaged well into the evening and makes going to sleep at a normal time highly problematic. There are no easy solutions, but being able to spot these and other patterns at least lets you know what you’re dealing with

So there you have it, rapid-cycling. The DSM has it wrong, no one studies it, no one knows how to treat it. Patients (and their families) suffer. Psychiatry owes you a huge apology.

Revised July 8, 2016






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