Bipolar Cycles - What are they?

What is a bipolar cycle?

Bipolar disorder is a psychiatric illness involving extreme cyclical and recurrent mood disturbance.

Clinical understanding of bipolar disorder has changed over time; bipolarity was previously considered a single disease and is now considered a spectrum of variations. This variation includes, among others, depressive episodes with short-lasting hypomania, depressive episodes, and also short, mixed, dysphoric episodes.

These different types of episodes can vary in length and severity, and someone can experience different episodes one after the other.

The frequency in which these episodes change from one to another is called ‘cycling.’ The patient can ‘cycle’ from a manic or hypomanic state to a depressive state for no apparent reason. This condition is considered an endogenous psychosis in which an episode of deep sadness alternates with an episode of exaltation, both of which are pathological.

How long do bipolar cycles last?

The development of bipolar spectrum disorder is variable, with cycles typically becoming shorter as more relapses occur. Research suggests a similar proportion of patients with an initial first episode of depressive or manic symptoms and a smaller proportion with mixed depressive and manic symptoms in around 20% of cases ^[3].

The duration of these episodes is highly variable, but in the case of an untreated manic episode, the average time usually ranges from two weeks to four months. Depressive episodes, on the other hand, tend to have a longer duration, reaching an average of six months.

In addition, the cycles of bipolar spectrum disorder usually have an average duration of two to three years, and the number of relapses varies from seven to 22 during the lifetime of the affected person ^[3].

The duration of these cycles will also depend on the type of bipolarity present :

• Bipolar I disorder is characterized byepisodes of mania lasting less than seven days and depressive episodes lasting at least two weeks. There may also be moments of mixed episodes or mood swings, with both depressive and manic features at the same time.
• Bipolar II disorder is characterized by deeper depressive episodes and lighter hypomanic episodes than those experiences in bipolar I.
• Cyclothymia, also known as cyclothymic disorder, is characterized by milder and less persistent depressive and hypomanic symptoms than bipolar I and II. Usually, cyclothymia lasts two years in adults and one year in adolescents and children.

What triggers bipolar episodes?

The causes of the onset of bipolar disorder are unclear. However, some factors may increase the likelihood of the development of the medical condition, such as:

• Genetic factors: The genetic background of a person may be related to a higher probability of experiencing bipolar disorder. It has been observed that those people with parents who have bipolar disorder have a 15% to 25% greater probability of developing it than those who do not have this background.
• Neurological factors: The imbalance in neurotransmitters, such as serotonin, noradrenaline,and dopamine, responsible for sending signals between neurons, causes a chemical alteration of the brain that increases the risk that the person may suffer from this disorder ^[4].

In general, there are a number of factors that may trigger bipolar disorder or that may be related to an increase in the chance of experiencing bipolar disorder. These triggers are usually related to the person's lifestyle and environment, especially if there is a genetic predisposition for this disorder. These include ^[5] :

• The use of drugs or alcohol,which may provoke the first episode, increase the symptoms or negatively alter the course of the disease.
• The presence of a bloodrelative with the disease.
• Traumatic experiences, such as the death of a close relative, abandonment, or continued abuse.
• Periods of prolonged stress
• Previous mental illness, such as anxiety or depression.
• Even the consumption of certain antidepressants, mainly tricyclics or norepinephrine reuptake inhibitors, can exacerbate the symptoms of the disorder.

What is rapid cycling bipolar disorder?

The term ‘rapid cycling’ in terms of bipolar episodes was first used by psychiatrists David Dunner and Ronald Fieve in 1974. It referred to patients with bipolar disorder who did not respond to treatment with lithium and who suffered frequent cycles of manic and depressive episodes over a year.

A person suffering from rapid cycling bipolar disorder has a succession of four or more episodes during twelve months, whether depressive, manic, hypomanic, or mixed. Each episode is separated from the next by a total or partial remission of about two months or by a drastic change to an episode of opposite symptomatology.

Rapid cycling bipolar disorder is not a sub-type but a complication of the condition. People suffering from rapid cycling present a higher risk of suicide since their depressive episodes are more severe and the response to drugs is very low. Therefore, a detailed and lengthy follow-up is essential in those patients who trigger rapid cycling episodes ^[6].

The few studies conducted on rapid cycling bipolar have not demonstrated an inherited genetic component nor the prevalence of certain traits as vulnerability factors for rapid cycling. Even so, certain types of people, how they act, and the characteristics of their form of bipolar, can make some people more likely to experience rapid cycling ^[7]:

• Patients with type II bipolar disorderhave a higher frequency of depressive episodes and risk of suicide.
• Substance misuse
• Presence of previous illnesses such as hypothyroidism or diabetes mellitus.
• People who are medicated with antidepressants.
• Presence of any brain damage.
• Patients who had their first episodes at an early age.
• Patients who suffer from long-lasting episodes.

Because it is a complication of bipolar disorder, the most common treatment plans should be reviewed and adjusted to the characteristics of the patient and the symptoms they present during the illness. In these types of cases, the following management strategies can be utilised ^[8]:

• Reviewing prescribed medication to balance mood and monitor the metabolism of these drugs in the patient.
• Investigating triggering factors of rapid cycling, such as drug use; the presence of a hidden disease, such as hypothyroidism; or other medications that may worsen symptoms, such as antidepressants, corticosteroids, or amphetamine derivatives.
• Facilitating mood stabilization through mood stabilizing drugs, antiepileptic drugs, thyroxine,or atypical antipsychotics.

In addition, therapeutic interventions with these patients can also support better management of symptoms, such as ^[9]:

• Creating a mood diary:In this record, note the characteristics of change, psychosocial stressors, hours of sleep, and treatment.
• Psychoeducation of the patient’sexperience of the mental health condition to enable
• Improve daily routines.
• Learning to manage environmental factors that can provoke stress.
• Building a therapeutic relationshipwith the patient and promoting shared decision-making in their care.
• To treat those illnesses associated with bipolar disorder,such as anxiety disorders.