Cyclothymic disorder

Cyclothymic disorder

Definition

Cyclothymic disorder, also known as cyclothymia, is a relatively mild form of bipolar II disorder characterized by mood swings that may appear to be almost within the normal range of emotions. These mood swings range from mild depression, or dysthymia, to mania of low intensity, or hypomania.

Description

Cyclothymic disorder, a symptomatically mild form of bipolar II disorder, involves mood swings ranging from mild depression to mild mania. It is possible for cyclothymia to go undiagnosed, and for individuals with the disorder to be unaware that they have a treatable disease. Individuals with cyclothymia may experience episodes of low-level depression, known as dysthymia; periods of intense energy, creativity, and/or irritability, known as hypomania; or they may alternate between both mood states. Like other bipolar disorders , cyclothymia is a chronic illness characterized by mood swings that can occur as often as every day and last for several days, weeks, months, or as long as two years. Individuals with this disorder are never free of symptoms of either hypomania or mild depression for more than two months at a time.

The noted psychiatrist Emil Kraepelin first described the symptoms of cyclothymic disorder in the late nineteenth century. Kraepelin described four types of personality disorders : depressive (gloomy); manic (cheerful and uninhibited); irritable (emotionally unstable and explosive); and cyclothymic. He viewed the irritable personality as simultaneously depressive and manic, and the cyclothymic personality as alternating between depressive and manic states.

Persons with cyclothymic disorder differ in the relative proportion of depressive versus hypomanic episodes that they experience. Some individuals have more frequent depressive episodes, whereas others are more likely to feel hypomanic. Most individuals who seek help for the disorder alternate between feelings of mild depression and intense irritability. Those who feel energized and creative when they are hypomanic, and who find their emotional low periods tolerable, may never seek treatment.

Causes and symptoms

Causes

Controversy exists over whether cyclothymic disorder is truly a mood disorder in either biological or psychological terms, or whether it belongs in the class of disorders known as personality disorders. Despite this controversy, most of the evidence from biological and genetic research supports the placement of cyclothymia within the mood disorder category.

Genetic data provide strong support that cyclothymia is indeed a mood disorder. About 30% of all patients with cyclothymia have family histories of bipolar I disorder, which involves full-blown manic episodes alternating with periods of relative emotional stability. Full-blown depressive episodes are frequently, but not always, part of the picture in bipolar I disorder. Reviews of the family histories of bipolar I patients show a tendency toward illnesses that alternate across generations: bipolar I in one generation, followed by cyclothymia in the next, followed again by bipolar I in the third generation. The general prevalence of cyclothymia in families with bipolar I diagnoses is much higher than in families with other mental disorders or in the general population. It has been reported that about one-third of patients with cyclothymic disorder subsequently develop a major mood disorder.

Most psychodynamic theorists believe that the psychosocial origins of cyclothymia lie in early traumas and unmet needs dating back to the earliest stages of childhood development. Hypomania has been described as a deficiency of self-criticism and an absence of inhibitions. The patient is believed to use denial to avoid external problems and internal feelings of depression. Hypomania is also believed to be frequently triggered by profound interpersonal loss. The false feeling of euphoria (giddy or intense happiness) that arises in such instances serves as a protection against painful feelings of sadness, and even possibly anger against the lost loved one.

Symptoms

The symptoms of cyclothymic disorder are identical to those of bipolar I disorder except that they are usually less severe. It is possible, however, for the symptoms of cyclothymia to be as intense as those of bipolar I, but of shorter duration. About one-half of all patients with cyclothymic disorder have depression as their major symptom. These persons are most likely to seek help for their symptoms, especially during their depressed episodes. Other patients with cyclothymic disorder experience primarily hypomanic symptoms. They are less likely to seek help than those who suffer primarily from depression. Almost all patients with cyclothymic disorder have periods of mixed symptoms (both depression and hypomania together) during which time they are highly irritable.

Cyclothymic disorder may cause disruption in all areas of the person's life. Many individuals with this disorder are unable to succeed in their professional or personal lives as a result of their symptoms. A few who suffer primarily from hypomanic episodes are high achievers who work long hours and require little sleep. A person's ability to manage the symptoms of the disorder depends upon a number of personal, social, and cultural factors.

The lives of most people suffering from cyclothymic disorder are difficult. The cycles of the disorder tend to be much shorter than in bipolar I. In cyclothymic disorder, mood changes are irregular and abrupt, and can occur within hours. While there are occasional periods of normal mood, the unpredictability of the patient's feelings and behavior creates great stress for him or her and for those who must live or work with the patient. Patients often feel that their moods are out of control. During mixed periods, when they are highly irritable, they may become involved in unprovoked arguments with family, friends, and co-workers, causing stress to all around them.

It is common for cyclothymic disorder patients to abuse alcohol and/or other drugs as a means of self-medicating. It is estimated that about 5–10% of all patients with cyclothymic disorder suffer also from substance dependence.

Demographics

Patients with cyclothymic disorder are estimated to constitute from 3–10% of all psychiatric outpatients. They may be particularly well represented among those with complaints about marital and interpersonal difficulties. In the general population, the lifetime chance of developing cyclothymic disorder is about 1%. The actual percentage of the general population with cyclothymia is probably somewhat higher, however, as many patients may not be aware that they have a treatable disease.

Cyclothymic disorder frequently coexists with borderline personality disorder , which is a severe lifelong illness characterized by emotional instability and relationship problems. An estimated 10% of outpatients and 20% of inpatients with borderline personality disorder have a coexisting diagnosis of cyclothymic disorder. The female-to-male ratio in cyclothymic disorder is approximately 3:2. It is estimated that 50%–75% of all patients develop the disorder between the ages of 15 and 25.

Diagnosis

The diagnosis of cyclothymic disorder is usually made when a person with the disorder is sufficiently disturbed by the symptoms or their consequences to seek help. While there are no laboratory tests or imaging studies that can detect the disorder as of 2002, the doctor will usually give the patient a general physical examination to rule out general medical conditions that are often associated with depressed mood. The doctor will also take a detailed medical and psychiatric history. If the patient's history or other aspects of his or her behavior during the interview suggest the diagnosis of cyclothymic disorder, the doctor may follow up the interview with the patient by talking with friends or family members to confirm the diagnosis.

The manual used by mental health professionals to diagnose mental illnesses is called the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision, also known as the DSM-IV-TR. This manual specifies six criteria that must be met for a diagnosis of cyclothymic disorder. These include:

• • Numerous episodes of hypomania and depression that are not severe enough to be considered major depression. These episodes must have lasted for at least two years.
• • During the same two-year period (one year for children and adolescents), the individual has not been free from either hypomania or mild depression for more than two months at a time.
• • No major depression, mania, or mixed (both depression and mania together) condition has been present during the first two years of the disorder.
• • The individual does not have a thought disorder such as schizophrenia or other psychotic condition.
• • The symptoms are not due to the direct effects of substance use (such as a drug of abuse or a prescribed medication) or to a medical condition.
• • The symptoms cause significant impairment in the patient's social, occupational, family, or other important areas of life functioning.

Treatments

Biological therapy

Medication is an important component of treatment for cyclothymic disorder. A class of drugs known as antimanic medications is usually the first line of treatment for these patients. Drugs such as lithium, carbamazepine (Tegretol), and sodium valproate (Depakene), have all been reported to be effective. While antidepressant medications might be prescribed, they should be used with caution, because these patients are highly susceptible to hypomanic or full-blown manic episodes induced by antidepressants. It is estimated that 40–50% of all patients with cyclothymic disorder who are treated with antidepressants experience such episodes.

Psychosocial therapy

Psychotherapy with individuals diagnosed with cyclothymic disorder is best directed toward increasing the patient's awareness of his or her condition and helping to develop effective coping strategies for mood swings. Often, considerable work is needed to improve the patient's relationships with family members and workplace colleagues because of damage done to these relationships during hypomanic episodes. Because cyclothymic disorder is a lifelong condition, psychotherapy is also a long-term commitment. Working with families of cyclothymic patients can help them adjust more effectively to the patients' mood swings as well.

Prognosis

While some patients later diagnosed with cyclothymic disorder were considered sensitive, hyperactive, or moody as children, the onset of cyclothymic disorder usually occurs gradually during the patient's late teens or early 20s. Often school performance becomes a problem along with difficulty establishing peer relationships. Approximately one-third of all patients with cyclothymic disorder develop a major mood disorder during their lifetime, usually bipolar II disorder.

Prevention

Cyclothymic disorder appears to have a strong genetic component. It is far more common among the first-degree biological relatives of persons with bipolar I disorder than among the general population. At this time, there are no known effective preventive measures that can reduce the risk of developing cyclothymic disorder. Genetic counseling, which assists a couple in understanding their risk of producing a child with the disorder, may be of some help.

See also Affect; Amitriptyline; Borderline personality disorder; Bupropion; Depression and depressive disorders overview; Fluoxetine; Mixed episode; Personality disorders

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association,2000.

Hales, Dianne, and Robert Hales, MD. Caring for the Mind: The Comprehensive Guide to Mental Health. New York: Bantam, 1995.

Kaplan, Harold I., MD, and Benjamin J. Sadock, MD. Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8th edition. Baltimore, MD, Lippincott Williams and Wilkins, 1998.

PERIODICALS

Akiskal, H. S. "Dysthymia and cyclothymia in psychiatric practice a century after Kraepelin." Journal of Affective Disorders 62 , no. 1-2 (January 2001): 17-31.

Angst, J. and A. Marneros. "Bipolarity from ancient to modern times: conception, birth and rebirth." Journal of Affective Disorders 67, no. 1-3 (December 2001): 3-19.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington, DC 20002. (202) 336-5500.

Mental Illness Foundation. 420 Lexington Avenue, Suite 2104, New York, NY 10170. (212) 682-4699.

Barbara S. Sternberg, Ph.D.