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Bipolar Disorder

The Bipolar Condition You Don't Hear About

Conceptualization, detection, and treatment of cyclothymia.

Key points

  • Cyclothymia is an under-recognized bipolar-spectrum illness.
  • Cyclothymia can be mistaken as a personality condition.
  • There is no gold standard of treatment for cyclothymia, but it is possible to manage the condition.
Source: Pixabay/OpenClipart-Vectors

What is classified as a bipolar-spectrum illness and rapidly cycles, but has no major depressive, manic, hypomanic, or mixed episodes?

Give up? Cyclothymia.

This perplexing mood roller coaster may be considered the "most neglected of mood disorders" (Perugia et al. in Carvalho & Vieta, 2017). Despite first being recognized in 1877 (Brieger & Maneros, 1997), comparatively little advancement has been made in cyclothymia's understanding and treatment. This is quite possibly due to an inability to agree upon its classification. A cursory review of the literature reveals three arguments about the condition:

  1. It is a fairly rare, stand-alone condition.
  2. It's just a prodromal phase of bipolar types 1 or 2.
  3. Cyclothymia is a matter of temperamental or "turbulent" personality.

This could sound confusing, as if one disorder is somehow three, but that's not the case. Indeed the above serves as yet another example of why critical thinking about diagnosis and careful attention to differentiation is so important.

Some readers may be wondering if they've missed the diagnostic mark on those complicated, perpetually moody patients who don't seem to improve no matter the amount of good, concerted effort. The good news? A sharp clinical eye can indeed help differentiate, which will help spur more pointed, and likely more successful, treatment.

Unfortunately, when diagnoses are challenging, a "good enough" diagnostic understanding may take effect. This leads to a generic "take your medications and here are some coping skills" approach, robbing patients of optimal treatment. For example, if careful observation points at a matter of personality, pharmacological interventions aren't likely to perform as brilliantly as in a bipolar illness.

The Cyclothymic Presentation

Cyclothymia differs in two major ways from its heavier-hitting relatives, bipolar types 1 and 2:

  1. It is a nebulous pattern of shuffling, depressive and hypomanic symptoms that don't meet full major depressive or hypomanic episode criteria. This may be that there are just a few symptoms present, or, perhaps there is a full symptom presentation, but the duration is fleeting.
  2. It is a chronic presentation without sustained periods of recovery. Specifically, it must last two years in adults and one year in children, and any symptom reprieve is short-lived at two months or less (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition [DSM 5]).
 Rodnae Productions/Pexels
Source: Rodnae Productions/Pexels

People with cyclothymia also tend to have a generally irascible, or easily angered disposition. In fact, Tomba et al. (2015) note that, in particular, cyclothymic patients are "often highly reactive to external stimuli."

While depression and hypomania can manifest irritability, we also must consider that living a life of constantly fluctuating moods is simply irritating, and thus conducive to angry reactivity,

Considering the illness tends to have an insidious onset and begins maturing in adolescence, it could easily be mistaken that "this is just the way the person is" and is their personality. Despite this, there are clues that clinicians can look for to tease out whether it is in fact a primary mood condition, or a matter of personality.

Considerations in Making a Cyclothymia Diagnosis

  1. It's important to rule out medical or substance-related causes of the moods. It is not unheard of, for example, for thyroid disease or birth control medication side effects to mimic cyclothymia symptoms.
  2. Given bipolar illnesses are genetic, if a patient presents with the above, consider cyclothymia if there is a reliable family history of cyclothymia or bipolar types 1 or 2. Just as schizophreniform often gives way to full schizophrenia, it is possible that cyclothymia may be a prelude to a maturing bipolar 1 or 2. Clinicians should remain vigilant to emerging full, sustained major depressive, hypomanic, manic, or mixed episodes.
  3. It's essential to rule out that the person's frequent mood alterations are not solely reactions to interpersonal or environmental matters. People with borderline personality disorder (BPD), for example, are often labile in mood. However, this tends to be reactivity to fears of abandonment/limits being set. It's important to rule out BPD, which, along with the diagnostic criteria, another "tell" is that person has a history of trauma/abandonment, along with a tendency for tempestuousness and an inability to tolerate limits even in their early years. It is possible a patient has both BPD and cyclothymia. Careful observation will detail that such patients are, at baseline, moody for no apparent reason, coupled with exacerbated moodiness in reaction to perceptions of abandonment/limits being set.
  4. Lastly, be sure that moods are not a matter of what Millon refers to as the exuberant personality (Millon, 2011). While not a well-known personality pathology, Millon proposed that this is essentially a baseline euphoric-hypomanic presentation without mood cycling as in bipolar conditions, but with a proneness to angry reactivity, especially when overwhelmed.

Treatment Implications

Clearly, if a personality diagnosis is culpable for the moods, personality-focused treatment must take place. If the moods are concluded to be cyclothymia, it's sound practice to make a referral to a psychiatrist who specializes in mood conditions.

For therapists, though it's a bipolar-spectrum illness, treatment isn't exactly the same as for types 1 and 2. In 1 and 2, we help a patient stabilize a mood episode, then work on maintaining stability. This is done, for example, through a focus on sleep hygiene and stress management, as lack of sleep and stress can encourage mania in bipolar patients. We also focus on managing "life issues" that may encourage depression, as mania often follows, and they're back in a cycle.

Unsplash/Amol Tyagi
Source: Unsplash/Amol Tyagi

In cyclothymia, however, the moods are so shuffling that there is no such "cut and dry" treatment. We can't work through a depressive spell and then simply focus on maintaining stability. Unfortunately, there is precious little research (e.g., Perugia et al., 2017; Tomba et al., 2017) on treatment approaches. Perugia does describe cases of remission and good prognosis if the condition is recognized early and intervened upon with pharmacology and therapy.

Until a "gold standard" is discovered, stress management can be highly effective, as stress exacerbates anything. This includes focusing on curbing reactivity; lifestyle changes, such as working towards regular exercise and a sound diet; and abstaining from substance use—especially caffeine. Being a stimulant, caffeine can compound any activation and irritation already at hand. Family therapy can also be helpful, as the nature of the condition can place strain on relationships, which, of course, brings on stress and exacerbates the moodiness.

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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)

Brieger, P., and Marneros, A. (1997). Dysthymia and cyclothymia: historical origins and contemporary development. Journal of Affective Disorders, 45(3), 117-26. doi: 10.1016/s0165-0327(97)00053-0.

Perugi, G., Hantouche, E., Vannucchi, G., & Pinto, O. (2015). Cyclothymia reloaded: A reappraisal of the most misconceived affective disorder. Journal of Affective Disorders, 183, 119-133.

Perugi, G., Vanucchi, G., & Mazzarini, L. (2017). The treatment of cyclothymia. In Carvalho, A.F., & Vieta, E. (Eds). The Treatment of Bipolar Disorder: Integrative Clinical Strategies and Future Directions (123-137). Oxford University Press.

Tomba, E., Tecuta, L., Guidi, J., Grandi, S., & Rafanelli, C. (2015). Demoralization and response to psychotherapy: A pilot study comparing the sequential combination of cognitive-behavioral therapy and well-being therapy with clinical management in cyclothymic disorder. Psychotherapy and Psychosomatics, 85(1), 56-57.

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