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    Joseph Goldberg, MD posted:
    A very useful website regarding bipolar disorder maintained by Massachusetts General Hospital.
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    49 of 134 found this helpful
    hope7951 responded:
    One thing I noticed is that this sticks with the DSM-IVTR difintions including the time lengths that define episodes. We have a large number of people here who talk about changing moods in a matter of seconds. I've always considered this to be reactive a life coping situation but some doctors are calling this ultraultra rapid cycling. What is your view on this reported symptom? Joye
    snowyowl33 responded:
    I am also interested in your thoughts on this, as the pdocs and specialists I have spoken with say that these "rigid" time lines in the DSM (printed 13 years ago I believe) for episodes are ony guidelines, and in real life, with real people there are many many variables that don't fit into this mold. Here in Canada docs us the term Ultra Rapid Cycling, if you are having "real" swings ( not just being pissed off because you burned your toast, and then crying at a kleenex commercial) on a more frequent basis... ie weekly or monthly... I have a dx of BP1 ultra rapid cycling and have had that for many many years, and three different docs agree including one of the best in I am very interested also to hear what you have to say... and thanks for the site link!
    Joseph Goldberg, MD replied to hope7951's response:
    I don't think the scientific community has a consensus about how best to classify mood states that change in a matter of seconds. Many things can cause this particular phenomenon other than bipolar disorder -- certain personality disorders, survivorship of emotional/physical/sexual trauma, PTSD, developmental disorders, adjustment disorders, drug or alcohol abuse, impulse control disorders, and other conditions. There are some authorities who feel based mainly on opinion that this phenomenon is related to bipolar disorder. But there are others who think that rapid mood changes are not specific to any diagnosis and, in and of themselves, are a symptom without necessarily a specific diagnosis. In people who have never had a manic or hypomanic episode by formal (DSM-IV) criteria, nobody can claim with any scientific confidence that any medicines have demonstrated and established value.

    I am leery of treating an isolated symptom in the absence of a clear diagnosis -- if and when I do, then I must remind myself and my patient that we cannot assume the results will be the same as when medicines are used for more clearly-defined bipolar I or II disorder. - Dr. G.
    Joseph Goldberg, MD replied to snowyowl33's response:
    Dear Snowyowl33,
    As I mentioned in my post to Joye, there is far more opinion than scientific fact or evidence to help anybody best understand what mood swings represent as a symptom. Rapid moodswings obviously can occur, for a wide range of reasons, and if they coincide with changes in the sleep/wake cycle, cognition, behavior, energy, and the other domains pertinent to bipolar disorder, then likely the mood symptoms are best conceptualized within that framework -- the same way if chest pain occurs in the context of exertion, nausea, sweating and shortness of breath, it is more likely anginal in origin than if it occurs at rest (costochondritis), or after eating (gallstones), or on an empty stomach (ulcers), or when taking deep breaths (pneumonia or rib fracture or pulmonary embolism) or after physical trauma (rib fracture)..... it is scientifically unsound to decontextualize a symptom apart from the broader constellation of signs and symptoms in which it occurs. Symptoms are not necessarily diagnoses in and of themselves. - Dr. G.
    hope7951 replied to Joseph Goldberg, MD's response:
    Thank you, Dr. Goldberg. Joye
    snowyowl33 replied to Joseph Goldberg, MD's response:
    Thanks Doc,

    I appreciate your response. Do you find in your practise that treating ultra rapid or rapid cycling BP1 (diagnosed already) patients are harder to find a continuing drug combo for, than say a patient who has BP with "normal" cycling? If so what types of combo's would ou look at?

    Here is a link to Dr. Sidney Kennedy... (maybe he is related to Jim Kennedy? I don't know)

    As always thank you for your time, and I haven't forgotten your initial question, I'm just thinking about my responce first...
    bprobin replied to snowyowl33's response:
    hey snowy. i hope the you are having a wonderul day! i have missed communicating with you!
    anyway....just incase i cant find this page....can you email me the docs reply to this post about ultra-rapid cycling bipolar meds please? i will reply to or write my own post but am still having a hard time finding them again. lol I dont know my way around a computer that much. thank you. robin
    snowyowl33 replied to bprobin's response:
    Hey Robin hon,

    Awesome to see you!! No problem re sending the Doc's reply re the thoughts on the types of meds good for dealing with ultra rapid cycling...I am looking forward to his thoughts too.

    Yes, I miss posting with you and everyone too... our group got pretty scattered, however, most of us are back in the exchange called Coconut Patch (named after all my lovely nuts!! lol) .. come and join us can find the exchange under Mental Health in the main index of exchanges...(I don't have the link on me right now sorry...)

    Ok hon, big hugs, have a fabulous day, and get outside and run around.. whooping and hollering. lol!

    Joseph Goldberg, MD replied to snowyowl33's response:

    I didn't comment on medication strategies for very rapid mood alternations -- whatever their diagnostic origins. Antidepressants likely are not so useful and may make moodswings worse -- unless the rapid mood shifts are thought to be a manifestation of borderline personality disorder, or PTSD, in which case SSRIs are the first-line treatment of choice. While there is no widely accepted "standard treatment" for very rapid mood shifts, most experts probably would advocate combinations of mood stabilizers -- ie, lithium /- Depakote /- Lamictal /- an atypical antipsychotic. There is an old study using the blood pressure drug nimodipine for ultra-rapid cycling in patients with established bipolar disorder -- but very expensive (330-360 mg/day at $10 per 30 mg...I leave the math to you). High-dose thyroid hormone (Synthroid or Cytomel) also has been looked at in rapid cycling per se (but not so much ultra-rapid or ultra-ultra-rapid cycling). There is a small literature on ECT for ultra-rapid cycling when no medicines work. Some mood stabilizing drugs also have been shown to work better for impulsivity or aggression than for mood per se in very rapid or so-called "labile" mood states -- Depakote, for example.
    I think it is important to consider whether it is mood per se that alternates fast or a constellation of mood energy sleep needs speech etc. It is much harder to treat just mood, maybe somewhat more modifiable to combine antimanic drugs when the associated symptoms of bipolar disorder besides mood are also present. Psychotherapies like DBT also can be very helpful when "affective dysregulation" (ie, extreme moodiness) occurs in and of itself. Hope this is helpful. - Dr. G.
    Joseph Goldberg, MD replied to snowyowl33's response:
    Truth be told, rapid cycling -- whether "traditional" (ie, 4 or more distinct, full episodes per year, with episodes lasting a minimum # of days, and separated by recovery) or just high lability -- is very hard to treat, and I dare say there are no excellent treatments. One of the better studies attempted was by Dr. Joseph Calabrese at Case Western, looking at lithium Depakote in combination. He found that only 1/4 of patients stabilized on this regimen over 20 months, and when then switched to either single drug, half relapsed. The lore tends to be avoiding antidepressants and combining antimanic drugs when many episodes per year occur. There has not yet been a systematic study of 3 or more such drugs (eg, lithium Depakote Lamictal Tegretol an atypical antipsychotic) but that's the general direction I move in with my own patients. A very tough problem unfortunately. - Dr. G.
    bprobin replied to Joseph Goldberg, MD's response:
    thank you, yes it did help. yea, without my meds, its like i am mania high for a couple 3 days, then i go into a deep depression for a couple weeks. i dont seem to remember a lot when im in that high state. thats how i have lived my life off and on for 20 plus years. the invega injections that i told you about seem to keep me on a stable ground. it for sure has calm my mind down so that I can think again. i use to trip over every word I said when I was on the mania high. now i have energy and life with my calm mind. almost to good to be true. lol
    thanks doc. robin
    bprobin replied to snowyowl33's response:
    hey sweetie. Im glad that I was able to stumble back on this page.yea I have missed you as well. I will try to find my way back to the coconut patch again. I think I did remember seeing it on the main page. thank you for being so nice.
    Im glad that we have the doc around. I am learning a lot from reading all of his post!
    see you soon!

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