Frequency of Cycling & Bipolar II
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Q:  Frequency of Cycling & Bipolar II

I have searched your archives as well as MHSource, PubMed and some other sources and have been unable to find any answer to my question.  I would like to know just how rapidly a person can cycle between depression and hypomania and have it be considered bipolar II? I have seen the DSM IV standard and know that some Dr.'s require the "up" be at least several hours to a day. I have also read the accounts of people going up and down within an hour, but can it be a matter of minutes?  I don't mean continuously, but a constant battle with depression then an exceedingly brief "high" that feels better than normal ever did. 

I'm asking because I was diagnosed with unipolar depression 8 years ago after a major episode brought on by trying birth control pills.  It was probably the 3rd or 4th episode I know of, though I don't remember ones from my youth. (have had depression since age of 12 - 13 and underwent some counseling then, am 39 now) and have been treatment resistant to basically every med and combination tried.  Also did therapy which did help.  I'm on Pamelor (200mg), Ritalin (120mg) and Topamax (400mg) now which has worked fairly well for several years, until recently.  Started having a few brief (10-20 minute) periods of the world shifting into slow motion, then going back to normal.  Had a major depressive episode in Nov. - first one since  getting it under control and I'm still notback up to where I was before.  Now I'm  experience short (5-10 minute) periods of feeling really good. Lots of ideas and energy and positive feelings, but no time to act on it, then back down to somewhat depressed. 

This all has me rather freaked out, as my father and aunt think that their mother may have been bipolar(never diagnosed, but did commit suicide) and grandmother was institutionalized.  My psych. Dr. and I both are hesitant to change my meds because it took several years of hell to find a combination that came close to keeping me alive and living a fairly normal life.  We have been playing with dosages instead.  I do take meds for blood pressure, allergies, allergy shots, iron and B12 (result of gastric bypass, which I would do again in a heartbeat).  I also take numerous vitamins and supplements and am rarely ill.  [I feel like I need to pass along some info on gastric bypass.  I read your response to someone about medication absorption after gastric bypass, and if they had the most common type performed today - the Roux en-y, their absorption would most definitely be affected.  True, the stomach is partitioned off, but the first 50-150cm of the upper small intestine is also   bypassed and the pouch (usable portion of stomach) is reconnected after that point.  Any meds that are absorbed in the intestines, particularly extended release, can be affected.  Also those that rely on stomach acid can be less effective, if my info is correct.  Lap Band or Vertical Banded Gastroplasty (VBG) don't bypass any of the small intestine.  Of course a bariatric surgeon would be the best resource on this - I'm just going on what my Dr. said 6 years (and over 200 lbs less of me) ago]

I have taken lithium in combination with other psych meds in the past and am hesitant to start again.  We discussed this at my last app't.  It gave me tremors and (whatever this is called) my hand would suddenly jerk violently.  I have also incorporated heavy-duty exercise into my life and sweat profusely (plus live in the south), and that might cause problems with lithium concentrations, particularly during the summer when I have my road races (race-walking, not running).  I am not willing to give up my new-found athleticism just yet.  

I have printed off some of your website to take to my Psych. Dr.'s office and get his opinion on as he's generally very open-minded.  Sorry this is so long and thanks for any insight/input you may have.


Dear Laura -- 
Thanks for the info' on stomach bypass. You're right, I was thinking Banding, not Rouex-en-y, as that's the procedure local to me. Interesting to hear that's not the most common.  Thank you for the correction there. 

As for your question, how fast can "cycling" be? -- this is rather debated in psychiatry, in part because it threatens the integrity of the idea of "diagnosis" in the traditional sense, which implies that a person is either normal or "diagnosable". If cycles can be so ultra-short as minutes, then how are we going to separate that out from normal human experience, say the worriers. And how is psychiatry to know who to treat, say the anti-psychiatry types; who also generally point out how much influence the pharmaceutical industry has, and usually strongly suggest that the movement toward a broader view of bipolar diagnosis is being driven by the drug companies and therefore to be mistrusted. The irony is that, in my view, there are very good reasons to broaden the view, and people just have to work toward accepting and coping with the complexities which accompany that approach -- because there are indeed complexities. In this view there is no longer any line at all, let alone a clear one, between "normal" and "bipolar".  Not good for a diagnostic system, but -- in my view -- closer to the clinical realities we see all the time, with people like you, for example. 

Sounds like these very brief few-minute episodes of energy you're having are, to you, very clearly not "normal", or at least not like anything you were used to experiencing before. So you have a very appropriate question, namely whether this represents "cycling". Of course the answer should be as fuzzy as the data; or put the other way, you'll only be able to be as certain about the answer to this question as you are about how clearly these episodes are different from your normal experience. If they are crystal-clear different, utterly obvious to you, and especially if they are similarly obvious to others, then you just have to have an explanation for them and one of the simplest such explanations would -- in my view -- be bipolar cycling, given the context you've described. Note, that's just a possible explanation, not necessarily the explanation (no diagnosis at a distance here...). 

So, with that rather lengthy intro', I think the article you'll want to get a librarian to help you find is the recent review by Drs. Mackinnon and Pies, both well-respected mood experts, on bipolar cycling and mixed states; that link will take you to a summary on my website with some of the key figures. If you haven't seen that one yet, I think you'll find it very useful in addressing your question. Not necessarily an answer, but useful. 

Dr. Phelps

Published October, 2006


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