Is it a bipolar mixed episode, ultra rapid cycling, or just “mood lability”?

mixed episode face

Putting a label on what’s happening to one’s mood can sometimes be difficult for people with bipolar disorder (BP). Having visited bipolar online forums for years, I encountered the questions in the title quite often. I know what is written in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5) and highly-regarded textbooks on the disorder, but that hasn’t always cleared up my occasional confusion, either. Some questions have been mostly answered, but others not fully. Truth is, answers can vary by mental health expert. Even the teams of doctors and consultants working on the DSM debated on some of its contents. Regardless, I hope some of what’s in this post is interesting food for thought.

As a person formally diagnosed with BP, I know that if I have hypomanic symptoms for at least four days in a row and meet all other required DSM-5 criteria for hypomania, then it’s clearly an official hypomanic episode. The same for a major depressive episode, but that requires a minimum of a 2-week period. Full blown mania? At least one week, or in this case, any duration if hospitalization is necessary. That’s basically what’s written in the DSM-5, but sometimes I have significant mood issues that end quicker, or don’t meet sufficient other required criteria. And what the heck really is the difference between a mixed episode and ultradian (ultra or ultra-rapid) cycling?

Mood Lability

Years back, I had the chance to regularly chat with a female psychologist online. She introduced me to the term “mood lability”. She and I both have bipolar disorder. If you google that term, it more often pops up in conjunction with borderline personality disorder (BPD) than bipolar disorder. Let’s put BPD aside right now. Discussing that disorder vs. bipolar disorder could be a very long conversation in itself. I’ll just say that her definition of “mood lability” in bipolar disorder was “any significant mood state period where insufficient episode criteria was met, according to the DSM-5”. So according to that friend’s definition, a person experiencing hypomanic type symptoms for two days only, or if say, fewer than three symptoms were experienced, an official hypomanic episode, by DSM-5 standards, was not met. However, I know that such short-term mood “blips”, as I call them, have happened to me. How about you or a bipolar loved one?

Mixed Episodes vs. Rapid Cycling (specifically ultra or ultradian cycling)

In the previous edition of the DSM (DSM-IV), the term “mixed episode” was frequently used as a type of episode. I won’t go into details, but the current DSM-5 edition, does not. Instead, they use specifiers as additions to either hypomanic, manic, or depressed episodes, such as adding “with mixed features”, “with rapid cycling”, and others. This new specifier approach allows for the dominant of the two episodes to be highlighted. For example, if a person has more depressive symptoms at a given time than hypomanic/manic (or more severe depressive symptoms than hypomanic/manic) then a possible episode label could be “Current episode depressed…with mixed features”.  I’m going to cease mentioning specifiers here, but I included it for a reason.

In previous DSM editions, “mixed states” (or mixed episodes) were when people with bipolar disorder were “both manic and depressed at the same time”. At the very same time?!?! Well, it is definitely possible for many. I know that I have had symptoms of hypomania or mania and depression simultaneously. I’ve had decreased need for sleep, been more talkative than usual, flight of ideas, and even other hypomanic/manic symptoms WHILE frantically depressed with suicidal or self-harming thoughts. Some people experience this, but say that the symptoms of one type of episode often fluctuate during the same day/week/month (all hypomanic/manic, then all depressed, back to all hypomanic/manic, etc.) Sometimes these experiences only last a day or two. Mood lability only? Or other times they are longer term, and actually meet the full criteria of an episode, according to DSM-5, of some sort.

If you have bipolar disorder, have you ever felt “stable” or observed someone with BP as “stable”, but they still complained about an issue, or two, that could be a symptom of a mood state? For example, your mood is fine, you are not racy, and yet…you lack a noticeable amount of energy. Perhaps it’s a medication side effect? A low-grade flu? Or maybe not. This has been particularly curious to me.

Powerpoint mixed episodes
All kinds of symptoms above, below, and at the baseline axis

OK, now I’m going to sort of link all of the above observations and questions.

An Interesting Expert Perspective on All of This
About a year ago, I decided to contact a respected psychiatrist to help end some this confusion. Dr. Jim Phelps has vast experience, and is a particular expert on bipolar spectrum disorders (particularly ones that don’t always fit neatly in a category). He was kind enough to provide a link to an article he wrote that helps shed some light on these issues. The link also contains other links to thoughts on topics like bipolar disorder vs. borderline personality disorder. He admittedly expresses disagreement with other experts, but comparing views can be interesting. I’m not suggesting his ideas are the absolute right ones, but as I said, it provides food for thought. Many people I’ve shared his link with have been particularly fascinated by his “wave theory”. I’ll let you choose to visit his website yourself rather than me poorly summarize it here. Let me know what you think.

Here’s his response to my email, with the mentioned link:

Hello [MyName] –
You have your finger on an area where our language is inadequate and often misleading [ultradian cycling vs. mixed states], as you’ve observed. So I think you’ll appreciate an article in which this very issue is addressed, including the very blurry interface with “mood lability” and borderlinity. Here’s my attempt to present the paper in plain English but you may want to get hold of the original.

Rapid Cycling And Mixed States As “Waves” | PsychEducation

I think this “waves” perspective helps a great deal in understanding rapid cycling (the very rapid kind) and mixed states. See if it makes sense for you –

Jim Phelps

If interested, Dr. Phelps has written some highly regarded books, one of which I own. Though I have type 1 bipolar disorder, during a particularly long depression of mine my husband bought me his book Why Am I Still Depressed? Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder. It’s a very interesting read for people with any type/form of bipolar disorder and even sheds some light on subtle differences between these main types. He also has a book about the bipolar spectrum. I have not yet read that book, but have read some of his views on this.


RESOURCES USED FOR THIS POST (Sorry, not listed in APA format)

Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition, American Psychiatric Association, Copyright 2013, ISBN 978-089042-554-1 (hardcover) or 978-0-89042-555-8 (paperback)

Surviving Manic Depression – A Manual on Bipolar Disorder For Patients, Families, and Providers, E. Fuller Torrey, M.D. and Michael B. Knable, D.O., Basic Books, Copyright 2002, ISBN-13 978-0-465-08664-1 and 10 0-465-08664-0

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