In this occasional feature, members of the Psych Congress Steering Committee and faculty answer questions asked by attendees at Psych Congress meetings.
QUESTION: How frequently or rapidly can patients cycle between depression and mania? What is the shortest time frame for such cycling?
ANSWER: This is a very important clinical issue. The concept of rapid cycling bipolar illness developed over the first half of 20th century. The modern concept of rapid cycling is based on the work of Dunner and Fieve in the 1970s. At that time, the rapid cycling modifier was used to designate a course of illness associated with 4 or more distinct mood episodes (depressive, manic, hypomanic, or mixed) during a 12-month period.
Cycling frequency is subject to significant individual variations, as episodes may occur within months or weeks of each other. When mood cycles are separated by days, this pattern is referred to as “ultra-rapid cycling”. “Ultradian cycling” is a term used to define mood shifts taking place within the same day. Ultra-rapid and ultradian cycling require further epidemiological/clinical validation based on rigorous methodology. Namely, rapid shifts in affective states may conflict with DSM-based definitions. The minimal duration of mania is 7 days, hypomania is 4 days, and depressive episode is 14 days. Geller and Tilman have proposed to resolve this contradiction by differentiating DSM-defined episodes from “cycles,” pertaining to distinctive mood shifts within an episode. These authors further suggested that one considers replacing the existing “rapid cycling” qualifier with a new term: “multiple episodes per year.”
In summary, the answer to our question depends on the definition we use. If one choses established DSM-based definitions (which equate “mood episode” and “cycle”), the briefest duration of the cycle will be 4 days. If one uses the later definition proposed by Geller and Tilman, where “cycles” are intra-episodic shifts in mood, the minimal duration may be measured in hours. The obvious quandary would lie in reliably differentiating ultradian cycles from mood instability.
—Psych Congress Steering Committee member Vladimir Maletic, MD, MS, Clinical Professor of Psychiatry and Behavioral Science, University of South Carolina School of Medicine, Greenville
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