Finding Love Among the Highs and Lows of Ultradian Bipolar Disorder

Psychiatric Times, Vol 38, Issue 4, Volume 04,

“As soon as Lexi reaches home, she abruptly sinks into depression and curls up in a fetal position, almost catatonic in her bed.”

REEL INSIGHTS

When Amazon Prime decided to base a television series on selected stories from the “Modern Love” column of The New York Times, I was excited. I had been an avid reader of the column, in which individuals reflect on the intricate nature of human relationships. The episode that struck me most was “Take Me As I Am, Whoever I Am,” based on the essay written by Terri Cheney in 2008.1 Then an entertainment lawyer, Terri wrote about her struggles with ultradian bipolar disorder, revealing how she hid her condition from her friends before ultimately going public.

In the series, Terri is played by Anne Hathaway. The Oscar-winning actress takes the viewer through the roller coaster of bipolar highs and lows. The episode begins with Lexi (Hathaway) during a manic high at a supermarket. She sports loud makeup, sequins, and bright clothes. She is instantly drawn to a man named Jeff and lands herself a date with him that week. The action segues into a flash-mob dance reminiscent of a scene in the movie La La Land.

As might be expected, the high does not last. As soon as Lexi reaches home, she abruptly sinks into depression and curls up in a fetal position, almost catatonic in her bed. While she does manage to wake herself up for the date, she appears slow, dysphoric, withdrawn, and unkempt, making Jeff wonder if she has a twin.

A few mornings later, Lexi wakes up—euphoric again—to the sound of birds chirping, and she calls Jeff for another date. However, by the time he arrives that night, she has flipped again, going from dancing around her apartment to sobbing uncontrollably on the bathroom floor. When Jeff walks away, she decides things need to change. She needs to give everyone a chance to know the real Lexi.

The episode illustrated how stigma often prevents individuals from getting the psychiatric help they need. Particularly unusual was the portrayal of a high-functioning lawyer with ultra-ultra rapid cycling (ultradian) bipolar disorder, an uncommon illness for even psychiatrists to see and diagnose. Lexi had almost no baseline or a euthymic phase.

As a portrayal of bipolar disorder, the episode has both strong and weak points. Hathaway’s portrayal of Lexi’s depression makes you feel empathetic. Crumpled on her bathroom floor in tears, hopeless and terrified, Lexi is a realistic portrayal of many patients’ experiences. Lexi’s mania, however, looks as glamorous as a Hollywood movie. She is super-productive and euphoric, with no impairment or mixed symptoms. Unfortunately, many patients will not be able to relate.

Pluses and minuses aside, it is heartening to think that viewers will see and empathize with Lexi’s struggles. Ultradian bipolar disorder can be difficult to recognize, even for psychiatrists, and it can be a controversial diagnosis to make.2 While 12% to 24% of patients with bipolar disorder experience rapid cycling (defined as 4 or more mood episodes in a year), the ultradian form is characterized by multiple episodes in a day. Some psychiatrists would prefer to classify it as a mixed state. Ultradian might also be mistaken for borderline personality disorder (BPD), but there are ways to distinguish them. For instance, mood cycling in BPD is closely tied to events in patients’ emotional lives, so it may appear random. In contrast, the underlying chemical disturbance in ultradian bipolar disorder leads to more regular mood cycling.

Despite its rarity, ultradian has been on psychiatrists’ radar for decades, and good treatment options are available. Robert M. Post, MD, and colleagues first described ultradian in the 1980s.3 Anticonvulsants like valproic acid and carbamazepine may be more effective for treatment than lithium. It is also important to reduce triggering factors like antidepressants, drugs of abuse, thyroid abnormalities, and irregular sleep schedules. There have been promising results with calcium channel blockers like nimodipine.4

In the episode’s final scene, Lexi finally opens up about her condition to a coworker. It is a powerful moment in which she likens the cathartic experience to an elephant lifting its foot off her chest. After a trial of several medications and electroconvulsive therapy, Lexi finds a new stability. She is ready to begin a new chapter in her life.

Cheney’s column and the episode both end with realistic hope: “I’ve finally accepted that there is no cure for the chemical imbalance in my brain, any more than there is a cure for love.”5

An earlier version of this article was posted ahead of print on March 9, 2021, with the following title: Handling the Highs and Lows of Ultradian Bipolar Disorder—and Love. -Ed

Dr Sinha is chief resident physician of psychiatry at the University of Missouri–Columbia.

References

1. Jones D. Modern Love: coming out as bipolar in Modern Love and reliving it on TV. The New York Times. October 18, 2019. Accessed February 15, 2021. https://www.nytimes.com/2019/10/18/style/anne-hathaway-modern-love-terri-cheney.html

2. Bauer M, Beaulieu S, Dunner DL, Lafer B, Kupka R. Rapid cycling bipolar disorder—diagnostic concepts. Bipolar Disord. 2008;10(1 Pt 2):153-162. doi:10.1111/j.1399-5618.2007.00560.x

3. Kramlinger KG, Post RM. Ultra-rapid and ultradian cycling in bipolar affective illness. Br J Psychiatry. 1996;168(3):314-323. doi:10.1192/bjp.168.3.314

4. The Carlat Psychiatry Podcast. Word of the day: ultradian cycling. Carlat Publishing. July 4, 2020. Accessed February 15, 2021. https://www.thecarlatreport.com/blog/word-of-the-day-ultradian-cycling/

5. Cheney T. Modern Love: take me as I am, whoever I am. The New York Times. January 13, 2008. Accessed February 15, 2021. https://www.nytimes.com/2008/01/13/style/modern-love-take-me-as-i-am-whoever-i-am.html