Perspectives on: Mixed Episodes vs. Ultradian Cycling and Mood Lability in BP and BPD

In a previous thread, an OP asked about mixed episodes vs. rapid cycling (ultradian cycling). I responded with things I had learned in DSMs and various books, but admittedly recognized that the topic brought up many questions in my mind, as well as confusion. I mentioned the term "mood lability" as one a psychologist friend mentioned to me when discussing significant mood issues that don't meet official episode criteria in manuals like the DSM-5. The topic of bipolar ultradian cycling vs. Borderline Personality Disorder was also hinted at in brief passing. It certainly is all very confusing these issues, and I know different psychiatrists have different views on them.

I decided to bring up the topics above to Dr. Jim Phelps, a well-known psychiatrist with vast experience, and 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 on this topic, which also contains links to other thoughts on these topics. 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 he sure provides food for thought.

Here's his response to my email:
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Hello [my name] -
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

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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.

Thank you for this BirdDancer. It’s a great read. I can really relate to what he said about the fact that some people don’t experience wellness in between different mood states.

——yes, yes, yes, the wave concept is right on!!!! Thank you so much. But now, what are the ramifications for meds controlling the waves when you rapid cycle? This gives me such hope! I will look for everything the “wave” author has written. BirdDancer, you are so, so, so special!

Mindblowing. Thanks for this.

Thanks for the read, BirdDancer.

The graphs in his article are so cool and informative. I agree with Dr.. Phelps about the limitations of the DSM V. I've had cycling where every few hours I'd have hypomanic-like symptoms and the news few hours suicidal, depressive symptoms, yet, as he says, the DSM V doesn't recognize these things as possible bipolar (if I'm understanding right).

Normally, if I'm consistently on my meds, I get 2-3 episodes a year. Otherwise, I rapid cycle like all f*** because I'm on/off them. In that case, I don't think it's bipolar or anything like that. I think it's just withdrawal symptoms.

In comparing myself to you, I feel like I'm BP 2, fwiw. I get psychosis all the time, but I don't think I ever get full-blown manic. I feel like the psychosis is a separate Dx, but whatever. I just think that's another issue with the DSM V.

I'm glad the article was of interest. For me, it said a whole lot on a number of levels.

I've never really been an ultraradian cycler, though I have had the 4 or more times per year basic rapid cycling one or two years in the past. I certainly have had several mixed episodes in my time, but the worst were clearly of the hypomanic/manic and depressive symptoms simultaneously kind. Mood lability as described in a page from a link in the main link, I've had many many many times! Mine is of the kind where I'll sometimes have 1/2 day of clear hypomania, then the next day feel pretty down in the dumps. I think the only time I ever had ultraradian cycling was when I was put on antidepressants. That was a clear trigger. When not on antidepressants, it was not an issue.

Another really interesting thing that Dr. Phelps wrote about was indeed that "wave" idea. I can have many days or weeks where I think "I'm stable. I'm not depressed. I'm not hypomanic/manic. Why am I lacking energy so much and have ZERO motivation?" Dr. Phelp's wave illustration seemed to really explain this.

Though I have bipolar 1 and do have these clearly perceived "stable" periods between clear major episodes that DO meet DSM-5 criteria, the issue I mentioned above (i.e. about having zero motivation when seemingly stable) is disabling enough to often prevent me from full functionality. Or sometimes I'm seemingly stable with energy, but extremely anxious, but not really depressed. Dr. Phelps' wave chart seemed to explain this, too.

A lot of time, the bipolar spectrum idea seems to mostly refer to the fact that some people who don't quite seem to qualify for a bipolar diagnosis (according to a DSM), have certain mood characteristics that are bipolaresque. I also see the spectrum as a concept that includes people who do have clear cut bipolar 1 or 2 histories, but whose illness courses don't quite resemble some other people's in the same "type" bracket. I think of when I read Kay Redfield Jamison's memoir "Unquiet Mind". I definitely related to a lot of what she wrote about, but other things not so much, at least not in this latter part of my life. We are also not the same in that Lithium (a miracle drug for her) does little for me. I see us having many similarities, but our unique differences. But we are all people with bipolar disorder. When people post and write "I think I have bipolar, but I wonder because I don't quite relate to you or you or you." That's OK, in my opinion. You have your own "flavor" of the illness, as my psychiatrist likes to say. That doesn't mean we should feel alone in our own flavor. We do relate on so many other levels.