While bipolar disorder affects both men and women, how the disorder is experienced and treated in both genders varies greatly. Women, for example, tend to experience more of the “rapid cycling” type of bipolar disorder.
Why is it that rapid cycling occurs more often in women? What other issues do women have to face with regards to having bipolar disorder? What should be the course of action for women (with bipolar disorder) who are contemplating pregnancy?
Types of Bipolar Disorder
There are several types of bipolar disorder. The main types include bipolar type I disorder, bipolar type II disorder, and cyclothymic disorder. Bipolar type I disorder is the “classic” form, and patients often experience at least one full or mixed episodes with major depressive episodes. Bipolar type II disorder is where patients have at least one milder form of mania and one major depressive episode. However, they never get a full manic or mixed episode. Bipolar II is more difficult to diagnose because some symptoms of hypomania may not be as apparent. Hypomania is described as a milder form of mania with less severe symptoms. The basic distinction between mania and hypomania is that mania can prevent a person from functioning on a day to day basis. That’s why it is so easy to overlook and misdiagnose a person as without bipolar disorder. Moreover, there are never any delusions in a hypomanic state. Lastly, in cyclothymic type of bipolar disorder, individuals suffer from many hypomanic and depressive symptoms (over 2 years, at least). It is interesting, however, that these symptoms are not severe enough or do not last long enough to be considered as a mood episode.
As told in its name, people with bipolar disorder have mood episodes that fall into two general categories: symptoms of mania and symptoms of depression. However, people diagnosed with bipolar disorder do not need to have symptoms of depression. In fact, people are often misdiagnosed with depression when bipolar disorder is actually the culprit. Thus, the symptoms of mania are key to the definition of having bipolar disorder. Symptoms of mania alone would be sufficient in diagnosing a person with bipolar disorder. The symptoms of mania include increased energy, activity, restlessness, racing thoughts, and rapid speech. The list continues with additional mania symptoms, such as excessive euphoria, extreme irritability and distractibility, decreased sleep requirement, uncharacteristically poor judgement, increased sexual drive, denial, and risky behavior. The symptoms of depression are also just as lengthy. These include persistent sad or empty mood, feelings of hopelessness, pessimism, guilt, worthlessness or hopelessness. Depression is also described as having decreased energy and thoughts of death or suicide. Overall, the specific symptoms and the severity of these mood episodes vary between individuals.
Bipolar Rapid Cycling in Women
Although bipolar illness is equally prevalent in both men and women, the course of the illness differs greatly between the sexes. This is especially true for conception and pregnancy, which affects both the course of the illness and the “treatment decisions that are made at various points in a woman’s life” (Leibenluft, 1997). A primary example of such a gender difference occurs with rapid cycling. As previously mentioned, rapid cycling is more prevalent in women. It is approximately three times more common in women than in men. Rapid cycling describes incidences where a bipolar patient experiences four or more episodes of mania, hypomania, or depression within a time period of a year (Leibenluft, 1997).
Why is rapid cycling bipolar disorder more common in women than in men? Three potential hypotheses to explain the higher prevalence of rapid cycling in women are hypothyroidism incidence, specific gonadal steroid effects, and the use of anti-depressant medications. First, more women encounter hypothyroidism than men do; however, there is not a general consensus on it being a primary cause of increased rapid cycling. Second, gonadal steroids, such as estrogen and progesterone, fluctuate throughout the menstrual cycle. Sixty-six percent of bipolar type I women had regular mood changes during either their menstrual or premenstrual phase of their cycle. They were more irritable and had increased anger outbursts (Blehar et al., 1998). These may set up women to frequent mood changes (especially prior to the menstrual cycle, as noted in the term “premenstrual syndrome”). Increased estrogen may cause women to develop hypercortisolism, which may increase the risk of depression. Stress levels are associated with cortisol level, so this may possibly be the reason for increased risk for depression.
People with bipolar disorder generally do not respond well to anti-depressant medications as the sole treatment. In fact, if taken alone, anti-depressant medications such as selective serotonin re-uptake inhibitors, tricyclics and monoamine oxidase inhibitors, may increase the manic episodes. They help alleviate the depression, but do not help the manic phases. Studies indicate that serotonin reuptake inhibitors and monoamine oxidase inhibitors are less likely to cause mania side effects, as compared with tricyclic antidepressants. Yet another study suggests that manic episodes caused by antidepressants are more moderate compared to those caused spontaneously. In addition, manic episodes caused by monoamine oxidase inhibitors are much milder than those caused by tricyclics or fluoxetine, also known as Prozac antidepressant (Leibenluft, 1998). This indicates that if a patient wanted to take antidepressants, then monoamine oxidases may be a better option. Again, there has not been enough evidence to suggest that any of the three hypotheses presented above is the absolute reason for increased rapid cycling in women with bipolar disorder. The treatments must be taken especially carefully, in order to account for all of the factors discussed.
The treatment of rapid cycling bipolar disorder is especially difficult. As mentioned above, treatment with anti-depressants may precipitate a switch to mania, but may also increase cycle frequency (Leibenluft, 1997). There needs to be more studies done in this area to confirm and treat these problems. However, the most helpful of all treatments is document daily what the moods are upon taking the appropriate drugs (anti-depressant/ antimanic). This will aid in the search for a better cure or prevention for both the short- and long-term treatment. It is probably best to minimize the use of anti-depressants and to maximize the use of mood-stabilizing agents. Mood-stabilizing agents are used to treat manic, hypomanic and mixed episodes and are used to prevent more mood episodes. This is not the absolute way, remember, because the use of mood-stabilizing agents is used primarily to treat mania. As with the problem of taking primarily anti-depressants, rapid cycling bipolar patients who use mainly mood-stabilizing agents will have severe depressive episodes. There is a trade-off between the use of either mood-stabilizing agents or anti-depressant drugs. Both decreases one problem while enhancing another. The absolute cure is still unknown.