Cyclothymic Disorder

Cyclothymic disorder is a milder form of bipolar disorder, characterized by episodes of hypomanic symptoms (elevated mood and euphoria) and depressive symptoms that last for at least two years.

Definition

Cyclothymic disorder, a mild form of bipolar disorder, is characterized by chronic, fluctuating mood swings—from symptoms of depression to symptoms of hypomania. These symptoms are not sufficient in number, severity, or duration to meet the full criteria for a hypomanic or depressive episode.

Hypomania involves periods of elevated mood, euphoria, and excitement but does not disconnect a person from reality. A person with cyclothymia experiences symptoms of hypomania but no full-blown manic episodes. Hypomania may feel good to the person who experiences it and may lead to enhanced functioning and productivity. Thus, even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that a problem exists. Without proper treatment, however, hypomania can become severe mania or can turn into depression.

For cyclothymic symptoms to be diagnosed, hypomanic symptoms and depressive symptoms must be present at separate times for at least two years. Approximately 0.4 percent to 1 percent of people will experience cyclothymia in their lifetime. The disorder usually begins in adolescence or early adulthood, and there is a 15 percent to 50 percent risk that a person with cyclothymic disorder will go on to develop bipolar I disorder or bipolar II disorder. This rate of risk is still too low to justify viewing cyclothymia as merely an early manifestation of bipolar type I disorder, as many people do recover and do not experience future symptoms of hypomania or depression. Cyclothymic disorder is equally common in males and females. 

Symptoms

For at least two years (one year for children and adolescents), the individual displays periods of hypomanic symptoms and periods of depressive symptoms that do not meet criteria for a hypomanic or major depressive episode.

Hypomanic symptoms are similar to manic symptoms but are shorter in duration and not as severe.

Signs and symptoms of hypomania include:

  • Increased energy, restlessness, and activity
  • Excessively "high," overly good, euphoric mood
  • Irritability
  • Racing thoughts and speech, jumping from one idea to another
  • Distractibility, inability to concentrate
  • Being more talkative than usual or feeling pressure to keep talking
  • Needing little sleep
  • Unrealistic beliefs in one's abilities and powers
  • Poor judgment
  • Spending sprees
  • A lasting period of behavior that is different from usual
  • Increased sex drive
  • Abuse of drugs, particularly cocaine, sleeping medications, and alcohol
  • Provocative, intrusive, or aggressive behavior
  • Denial that anything is wrong

A hypomanic episode is diagnosed if elevated mood occurs alongside three or more other symptoms most of the day, nearly every day, for four days or longer. If the mood is irritable, four additional symptoms must be present. A manic episode is diagnosed if symptoms continue for one week or longer.

Depressive symptoms include:

  • Persistent sadness
  • Fatigue or listlessness
  • Excessive sleepiness OR inability to sleep
  • Loss of appetite and weight loss OR overeating and weight gain
  • Loss of self-esteem
  • Feelings of worthlessness, hopelessness and, or, guilt
  • Difficulty concentrating, remembering, or making decisions
  • Withdrawal from friends
  • Withdrawal from activities that were once enjoyed
  • Persistent thoughts of death

An individual may be diagnosed with cyclothymic disorder if:

  • During the two-year period (one year for younger patients), symptoms are not absent for more than two consecutive months.
  • The patient has never had a major depressive episode or any manic or mixed manic episodes.
  • The disorder does not exist only in the context of a psychotic disorder.
  • Symptoms are not directly a result of a medical condition or substance usage.
  • Symptoms result in significant distress or impaired functioning in social, work, or personal areas.

It is not uncommon for people with cyclothymic disorder to also have diagnoses of substance-related disorders and sleep disorders. Children with cyclothymic disorder are also more likely to have attention-deficit/hyperactivity disorder than other pediatric patients. 

Causes

The cause of cyclothymic disorder is unknown. Although mood swings are irregular and abrupt, the severity of the mood swings is far less extreme than in people with bipolar disorder (manic-depressive illness). Unlike with bipolar disorder, periods of hypomania do not turn into mania, in which the person may lose control over his or her behavior and go on spending binges, engage in risky sexual behavior or drug use, and lose touch with reality.

Hypomanic periods are energizing and can result in productivity for some people, while for others these periods can cause impulsive and callous behavior, which can damage relationships. Because hypomania feels good, people with cyclothymia may not seek treatment.

To understand the causes of cyclothymia, it may be useful to explore the causes of bipolar disorder.

Most scientists now agree that there is no single cause of bipolar disorders—rather, many factors act together to produce these conditions. It is known, however, that major depressive disorder, bipolar I disorder, and bipolar II disorder are more common among close biological relatives of individuals with cyclothymic disorder. 

Because bipolar disorders tend to run in families, researchers search for specific genes that may increase an individual's chance of developing the illness. But genes are not the whole story. Studies of identical twins, who share all the same genes, indicate that both genes and other factors play a role in bipolar disorder. If bipolar disorder were caused entirely by genes, then the identical twin of someone with the illness would always develop it, and this is not the case. But if one twin has bipolar disorder, the other twin is more likely to develop it than is another nontwin sibling.

Bipolar disorder, like other mental illnesses, does not occur because of a single gene. It appears likely that many different genes act together, and in combination with other factors of the individual or in the individual's environment. Finding these genes, each of which contributes only a small amount toward the likelihood of bipolar disorder, has been extremely difficult. But scientists expect that advanced research tools currently in use will lead to more effective treatments. 

Treatments

Treatment for cyclothymia is similar to treatment for bipolar I disorder and bipolar II disorder. The level of treatment is dependent on the severity of symptoms. 

Most people with bipolar disorder—even the most severe forms—can achieve substantial stabilization of their symptoms with proper treatment. Because this is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychotherapy is optimal for managing bipolar disorder over time.

In most cases, bipolar disorder is much better controlled if treatment is continuous than if it is sporadic. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately to the doctor. The doctor may be able to prevent a full-blown episode by making adjustments to the treatment plan. Working closely with a professional and communicating openly about any concerns and options can make a difference in treatment effectiveness.

In addition, keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events may help people with bipolar disorder and their families to better understand the illness. This chart also can help the doctor track and treat the illness most effectively.

Medications for the disorder are prescribed by psychiatrists. While primary care physicians who do not specialize in psychiatry also may prescribe medications, it is preferred that people with bipolar disorder see a psychiatrist for treatment.

Mood stabilizers usually are prescribed to help control bipolar disorder. Several different types are available. In general, people with bipolar disorder continue treatment with mood stabilizers for extended periods of time. Other medications are added as required, typically for shorter periods, to treat episodes of mania or depression that break through despite the mood stabilizer.

Lithium, approved for the treatment of acute mania in 1970 by the U.S. Food and Drug Administration (FDA), has been an effective mood-stabilizing medication for many people with bipolar disorder.

Anticonvulsant medications, particularly valproate and carbamazepine, have been used as alternatives to lithium in many cases. Newer anticonvulsant medications, including lamotrigine, gabapentin and topiramate, are being studied to determine their efficacy as mood stabilizers in bipolar disorder. Some research suggests that different combinations of lithium and anticonvulsants may be helpful. It is important to note, however, that some people with cyclothymia may not respond to medication as well as people with bipolar I disorder or bipolar II disorder. 

Children and adolescents with bipolar disorder are generally treated with lithium, but valproate and carbamazepine are helpful as well. Researchers are studying the safety and efficacy of these and other psychotropic medications in children and adolescents. There is some evidence that valproate may lead to adverse hormone changes in teenage girls and polycystic ovary syndrome in women who began taking the medication before age 20. Therefore, young female patients taking valproate should be monitored carefully by a physician.

Women with bipolar disorder who wish to conceive, or who become pregnant, face special challenges due to the possible harmful effects of existing mood stabilizing medications on the developing fetus and the nursing infant. The benefits and risks of all available options should be discussed with a clinician skilled in this area. New treatments with reduced risks during pregnancy and lactation are currently being studied.

Changes to the treatment plan may be needed at various times. A psychiatrist should guide any changes in type or dose of medication.

Be sure to tell the psychiatrist about all other prescription drugs, over-the-counter medications, or natural supplements you may be taking. This is crucial because certain medications and supplements mixed together may cause adverse reactions. To reduce the chance of relapse, it is wise to stick to the treatment plan. Talk to your doctor if you have any concerns about the medications.

As an addition to medication, psychosocial treatments—including certain forms of psychotherapy (or "talk" therapy)—can provide support, education, and guidance to those struggling with bipolar disorder and their families. Studies have shown that psychosocial interventions can lead to increased mood stability, fewer hospitalizations, and sharper functioning in several areas. A licensed psychologist, social worker, or counselor typically provides these therapies, often working with the psychiatrist to monitor a patient's progress. The number, frequency, and type of sessions should be based on the treatment needs of each person. Certain types of psychotherapy or other interventions, in combination with medication, can offer additional benefit. These include cognitive-behavioral therapy, interpersonal and social rhythm therapy, family therapy and psychoeducation.

References

  • American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
  • American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
  • National Institutes of Health
  • National Institutes of Mental Health, Genetics Workgroup
  • US Public Heath Service ,Office of Surgeon General

Last reviewed 03/20/2017