Cyclothymia (cyclothymic disorder)

Cyclothymia or cyclothymic disorder is a mood disorder that causes moderate emotional swings. It is a type of bipolar disorder with highs and lows that are not as extreme as those in bipolar I or II. Cyclothymia is frequently misdiagnosed as depression because individuals are more likely to seek help during depressive episodes. However, many avoid seeking treatment because they do not feel it is necessary. Unpredictable mood shifts can interfere with daily functioning. Medications and talk therapy are among treatments available.

Background

Bipolar disorder first appeared in the medical literature of ancient Greece. Physician Hippocrates (460–370 BCE) described the extreme moods that in modern times are known as mania and depression. He called extreme sadness melancholia, from melas meaning “black” and chole meaning “bile.” He believed that too much black bile caused sadness, and an abundance of yellow bile resulted in mania. Another Greek physician, Aretaeus of Cappadocia, was the first to connect melancholia and mania to the brain in the first century. He also described moods as a spectrum of feeling with these extremes at either end. Though they had different ideas, both recognized that mania and melancholia were based in biology.

Hippocrates’s and Aretaeus’s belief that the two were separate conditions persisted for centuries. During the nineteenth century, multiple psychiatrists first recognized that depression and mania were part of a single disorder. French psychiatrist Jean-Pierre Falret called it folie circulaire, describing it as a continuous but variably spaced cycle of mania and depression. Jules Baillarger, a French psychiatrist and neurologist, called it folie à double forme. He did not recognize intervals between the extreme highs and lows as part of the disorder. German psychiatrist Emil Kraepelin, known as the founder of modern psychiatry, described all affective or mood disorders as manic-depressive insanity.

Mental health professionals of the twentieth century worked to categorize and standardize the diagnosis of mental illness. They created the first edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-1, in the 1950s. The DSM is the standard guide in the United States and many other countries to mental disorders and includes symptoms, descriptions, and other means to diagnose mental disorders. New editions with updated information are published periodically. In the DSM-1, Kraepelin’s manic-depressive insanity was categorized as three conditions: manic, depressive, and other. The latter included the condition that would come to be known as bipolar disorder. DSM-3, published in 1980, first identified bipolar disorder by name and defined it as being separate from generalized depression. Eventually, bipolar disorder was divided into four types: bipolar I, bipolar II, cyclothymic disorder, and unspecified bipolar disorder.

Overview

Cyclothymic disorder is estimated to affect from 0.4 percent to 2.5 percent of the population. It is less diagnosed in certain cultures and minority populations, which are typically underserved. Researchers believe that this misdiagnosis is because it shares symptoms of other disorders. It usually emerges in adolescence or early adulthood and is believed to affect men and women equally, although women are more likely to seek treatment. Like other bipolar disorders and depression, it often runs in families and experts suspect a genetic link. Individuals with cyclothymic disorder are more likely to also have attention-deficit/hyperactivity disorder (ADHD) and sleep disorders and are at greater risk of substance abuse.

Cyclothymia and other bipolar disorders and major depression have been linked to some experiences. Individuals who have experienced trauma and stress of long duration, such as physical abuse, are more likely to develop cyclothymia.

According to the American Psychiatric Association’s DSM-5, published in 2013, symptoms of cyclothymic disorder include brief hypomanic and mild depressive episodes. Hypomanic episodes are less severe manic episodes. Cyclothymic disorder is more chronic than other bipolar disorders, although in some individuals it appears to gradually decrease and disappear. It can increase one’s chances of developing a more severe form of bipolar disorder. Estimates of this increased risk range from 15 percent to 50 percent. The disorder can disrupt family and work relationships and lead individuals to make poor choices that lead to legal and financial problems.

Examples of manic moods and behavior include high energy and energetic actions, extreme optimism, racing thoughts, poor judgment, impulsivity, irresponsibility, recklessness, trouble concentrating, and a decreased need for sleep. Feelings include elation, optimism, irritability, agitation, and a tendency to overreact to events. Depressive episodes may involve feelings of indifference, sadness, emptiness, guilt, worthlessness, or hopelessness. Other symptoms include restlessness, sleeping much more or much less than usual, difficulty concentrating, suicidal thoughts, lack of purpose, loss of pleasure in activities that the individual previously enjoyed, and withdrawal from social situations.

A diagnosis of cyclothymic disorder may be made if an individual meets all the diagnostic criteria. In adults, the hypomanic and depressive symptoms have to have lasted at least two years, and none has met the criteria for manic or major depressive episodes. In children and adolescents, a duration of one year is required for diagnosis. Periods of normal mood last less than eight weeks. Hypomanic and depressive symptoms are present at least 50 percent of the time, not caused by medical conditions or substance abuse, and not absent for more than a two-month period. Other mental disorders must be ruled out as contributing to the symptoms. The hypomanic and depressive symptoms are causing disruptions in the patient’s life in areas such as relationships and work.

A medical provider or mental health professional seeking to diagnose a patient’s symptoms will typically first order tests to rule out medications or medical conditions as the cause. Assessments can help determine the occurrence and duration of symptoms. Information about a person’s family history of mood disorders and a daily diary documenting mood swings can also be used to develop a mood history.

Treatment can lower the patient’s risk of developing bipolar I or II. Common options are medication and psychotherapy with the goal of decreasing depressive and hypomanic symptoms. Doctors often prescribe medications used to treat bipolar I and II, such as anticonvulsants and second-generation antipsychotics such as lithium. Antidepressants have not been effective. Therapy can offer techniques to manage symptoms and cope with stress. Among types found to be helpful for some patients are cognitive behavioral therapy, which teaches individuals to change negative thoughts to positive ones, identify trigger points, and manage stress; dialectical behavior therapy, which teaches one to be aware, cope with stress, and regulate emotions; and interpersonal and social rhythm therapy, which can help to stabilize moods through establishing and sticking with routines such as sleep and wake cycles.

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