Handling the Highs and Lows of Ultradian Bipolar Disorder—and Love

A high-powered lawyer faces her toughest opponent yet: mental illness stigma.

When Amazon Prime decided to stream selected stories from the “Modern Love” column of The New York Times, I was excited. I had been an avid reader of this section, where individuals reflect on the intricate nature of human relationships. The episode that struck me 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 television series, Terri is played by Anna Hathaway, the Oscar-winning actress who takes you through the roller coaster of bipolar highs and lows. The episode starts with Lexi (Hathaway) during her 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 scene breaks into a flash mob dance reminiscent of the movie La La Land.

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 While she does manage to wake herself up for the date, she appears slow, dysphoric, withdrawn, and unkempt, making Jeff wonder if she has a twin.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, she wakes up, euphoric again, to the sound of birds chirping and 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 that things need to change. She needs to give everyone a chance to know the real her.

The episode illustrated how the stigma of mental illness keeps people from getting the help they need. What was unique was the portrayal of a high-functioning lawyer with ultra-ultra rapid cycling (ultradian) bipolar disorder, an uncommon diagnosis for even psychiatrists to make or witness. Lexi almost had no baseline or a euthymic phase. As a portrayal of bipolar disorder, the episode has its 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 sympathize with Lexi’s condition. Ultradian 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 (a total of 4 or more mood episodes in a year), ultradian 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 the disorders. BPD mood cycling is closely tied to events in patients’ emotional lives, so it may appear random. In contrast, the underlying chemical disturbance in ultradian bipolar disorder will lead 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 might 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 are promising results on calcium channel blockers like nimodipine.4

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

Cheney’s column and the episode 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

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

References

1. Jones D. 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, et al. Rapid cycling bipolar disorder—diagnostic concepts. Bipolar Disord. 2008;10(1 Pt 2):153-62.

3. Kramlinger KG, Post RM. Ultra-rapid and ultradian cycling in bipolar affective illness. Br J Psychiatry. 1996;168(3):314-23.

4. The Carlat Psychiatry Podcast. Word of the day: ultradian cycling. Published July 4, 2020. Accessed February 15, 2021.

https://www.thecarlatreport.com/blog/word-of-the-day-ultradian-cycling/

5. Cheney T. 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