Rapid Cycling and Mixed states as “Waves”

http://www.bipolar4lifesupport.co

Rapid Cycling and Mixed States as
“Waves”
(April 2006)

The three color pictures on this page are from Drs. Dean Mackinnon and Ron
Pies, used with their permission from their article on “affective
instability”.Mackinnon
This term means, roughly, unstable mood and energy. People with such
instability have big changes in their mood, or energy, or creativity over time.
They may have easy tearfulness, such as crying over a commercial on TV. They
may have extreme episodes of anger, often over a minor event. They can
sometimes have inappropriate “mirth” — laughing too loud or too long, or being
too giddy or goofy — although, isn’t it interesting, that’s not a problem I
hear about much! Drs. Mackinnon and Pies offered a new explanation for this
instability, which I have tried to “translate” in three steps below. Their
model is quite different from the current diagnostic system for bipolar
disorder.

You see, according to the current official rules of diagnosis (the DSM),
“mixed states” include only phases of full manic and full depressive symptoms..
(If the idea that these can occur together is news to you, better jump
back to the main page on diagnosis and return
here after that; for best navigation of the entire bipolar portion of this
website, use this introduction). Similarly,
those same rules only allow cycles as short as 4 days. Any shorter doesn’t fit
on the DSM map.

But patients do have other combinations of depression and hypomania,
or mania — not just the two worst phases together. And they do have
cycles shorter than 4 days. The DSM can’t really handle these variations, but
the model shown here handles them very well. When I show these pictures to my
patients, I often see the “light bulb” go on in their head.

Although these pictures are just a model, they explain how symptoms shift
over time in a way that seems a lot closer to what some people live through than
the typical stories about bipolar disorder — you know, the ones that talk about
“manic episodes” as though they were completely separate phases followed
by relatively normal functioning. For a lot of people, there are no phases of
normal functioning (or very brief ones); instead, many people have only
symptoms, varying from one kind to another. See if this model makes sense of
your experience. Although I’ve changed Dr. Pies’ and Mackinnon’s presentation a
bit, this model is still theirs (doctors and NP’s and therapists should really
try to get hold of the article
itself).

Step One: Symptoms vary separately from one another, and at different
rates.

Here the green curve represents mood, the red curve represents energy, and
the black curve represents “intellect” (speed of thought, creativity, ability to
connect ideas).
As you can see, if they all go up together — and far enough “up” — this
would be what is commonly called a manic or hypomanic episode, as shown at point
A on the graph. If they all come down together, far enough, that would be an
episode of “major depression”, as shown at point B. But now we can see how
“agitated depression” could be part of a bipolar problem, when the energy curve
is up while the others are down, as at point D.
Point C represents an unusual combination usually recognized only on
inpatient psychiatry units, when a person is agitated yet hardly moves,
so-called “manic stupor”. But imagine what a milder version of this would look
like: the person would know she needed to get moving, indeed she would be
thinking of many things she needed to be doing, and she might really want (in a
very powerful way) to be doing them, and yet her body would refuse to go along.
She would be lying there on the couch, miserable yet not really depressed,
wondering what was wrong with her and why she couldn’t get herself going.

Point B represents another very important combination we psychiatrists see
commonly: the energy wave is up, but the mood wave is down (in this case, the
timing is such that the intellect wave is up too, but not as high as the energy
— yet there are many combinations, as you’ll see in a moment). This
could be called “dysphoric mania”: energized, as in a usual manic phase, but
mood is very negative.

The curves are shown here as neat, smooth waves, but reality seems to be even
more unpredictable: the waves have long humps sometimes, and short humps at
others; and long troughs, or short troughs, as well. Imagine what someone would
look like who had very long troughs of mood, and only little humps of energy
that came along rarely; and imagine if that person also had a rough childhood,
and was “temperamentally” (their style, from birth) tilted toward depression.
He might be depressed most of the time, as his “baseline”; with phases of
depression, some long, some shorter, and only rare phases of feeling like “the
rest of the human population”. His curve of mood might look like this:

That’s a Phelps’ graph, from my book, representing the experience
of a lot of patients I see — not a Mackinnon/Pies graph). Then complicate that
pattern with similarly irregular curves, varying independently, of energy and
intellect. What a mess! No wonder psychiatrists have clung to a simplifying
model like the DSM. There are nearly an infinite variety of possible
mood/energy/intellect combinations and patterns over time. However, they all
have the same three ingredients, and one common theme: cycling —
variation within a typical range over time.

Step Two: The waves can come at nearly any speed.
This might seem fairly logical and it certainly matches my experience with
patients, but it doesn’t match the official rules of diagnosis: bipolar disorder
is supposed to have phases lasting at least 4 days. Shorter than that, and it
doesn’t fit the official model. But the shorter versions are seen so often they
have their own names, as shown below.

Now one would have to admit that when the “cycles” get so short there are
multiple moods in a day, the condition gets hard to distinguish from “normal
emotions” — normal reactions to events that last a few minutes or even close to
an hour or so. Yet this ultra-ultra-rapid cycling (“ultradian”) is quite
commonly seen in kids who have bipolar disorder, where it can be so extreme as
to be clearly recognizable as “not a normal emotional reaction.”).

Now, we combine the first two steps to reach the most important implications
of the third step below.

Step Three: How waves lead to continuous — and continuously varying —
symptoms.

Many people with Bipolar II do not have the “well intervals”, in between
periods of having symptoms, that are often spoken of in websites and books about
Bipolar I. This leaves them somewhat puzzled. Do they really have “bipolar
disorder?” Why, they never really have “episodes”, let alone “manic” episodes.

Yet as the following graph shows, a rapid cycling of the individual symptoms,
at different rates, can create a varying pattern of nearly continuous
symptoms. Instead of having identifiable “episodes”, this person has almost
constantly shifting symptom phases that blend into one another.

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