______is the key feature of cyclothymia.
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Cyclothymia, or cyclothymic disorder, causes mood changes – from feeling low to emotional highs. Cyclothymia has many similarities to bipolar disorder. Most people's symptoms are mild enough that they do not seek mental health treatment, or the emotional highs feel nice, so they do not realise there's
anything wrong or want to seek help. This means cyclothymia often goes undiagnosed and untreated. But the mood swings can affect daily life, and cause problems with personal and work relationships. If you think you have cyclothymia, it's important to seek help from a GP. People with cyclothymia are at risk of developing bipolar disorder, so it's important to get help before
reaching this stage. Men and women of any age can get cyclothymia, but it's more common in women. If you have cyclothymia, you'll have periods of feeling low followed by periods of extreme happiness and excitement (called hypomania) when you do not need much sleep and feel that you have a lot of energy. The periods of low mood do not
last long enough and are not severe enough to be diagnosed as clinical depression. You might feel sluggish and lose interest in things during these periods, but this should not stop you going about your day-to-day life. Mood swings will be fairly frequent – you will not go for longer than 2 months without experiencing low mood or an emotional high. Symptoms of cyclothymia are not severe enough for you to be diagnosed with bipolar disorder, and your mood swings will be broken up by periods of normal mood. Treatment usually involves medicine and some kind of talking therapy (psychotherapy). The aim is to: You'll probably need to continue this treatment for the rest of your life. You may be prescribed: Mood stabilisers include: Antidepressants may help improve your low moods, but they may cause you to switch to the other extreme of hypomania. Recently, some antipsychotics such as quetiapine have also been used as mood stabilisers. But not all people
with cyclothymia respond to medicine. The charity Mind has more information on lithium and other mood stabilisers. Psychotherapy, such as cognitive behavioural therapy
(CBT), can help with cyclothymia. CBT involves talking to a trained therapist to find ways to help you manage your symptoms by changing the way you think and behave. You'll be given practical ways to improve your state of mind on a daily basis. Further support for cyclothymiaFind your nearest mental health support service You may also find it helpful to join a support group so you can talk to others who share your experiences and problems. You can ask your mental health service or GP if there's a local group you can join. Read about depression support groups Other organisations that can help include:
Living with cyclothymiaIt's not known how many people with cyclothymia will go on to develop bipolar disorder. But some people with cyclothymia see their elevated or depressed moods become more severe. Other people will find their cyclothymia continues and they need to manage this as a lifelong condition. Causes of cyclothymiaThe causes of cyclothymia are not known, but there's probably a genetic link because cyclothymia, depression and bipolar disorder all tend to run in families. In some people, traumatic events or experiences may act as a trigger for the condition, such as severe illness or long periods of stress. Page last reviewed: 10 December 2020 Continuing Education ActivityCyclothymia is an affective disorder characterized by emotional reactivity and affective dysregulation. Often this disorder presents a challenge for the clinician as many patients present with non-specific symptoms and may be mistaken for similarly manifesting psychiatric disorders. This activity will review the evaluation, diagnosis, and treatment of cyclothymia and highlights the importance of an interprofessional team in its treatment. Objectives:
Access free multiple choice questions on this topic. IntroductionCyclothymia is a primary mood disorder that is connotated with great ambiguity and controversy. The primacy of the disorder is inherently nebulous as it shares diagnostic features with a multiplicity of disorders. Cyclothymia is characterized by episodes consisting of hypomanic and depressive symptoms that do not meet the full criteria for bipolar or major depressive disorder. Furthermore, its manifestations onset early in life, demonstrable via temperamental mood reactivity and dysregulation. The complexity of the disorder makes it difficult to identify in clinical practice. In DSM-5, it is subsumed under the category of bipolar mood disorders. Cyclothymia is somewhat analogous to personality disorders as its onset is early and its course is chronic and pervasive. In fact, cyclothymia is often misconstrued with cluster-B personality disorders. Because of overlapping diagnostic criteria, it can be easily misdiagnosed. As with other psychiatric disorders, it leads to dysfunction and distress. While many psychiatric disorders may precipitate in the setting of cyclothymic disorder, the reciprocal is not valid. For example, although often comorbid with substance use disorders, by definition, cyclothymia is not induced by substance use. Although equivocal in nature, a detailed and careful evaluation can enable clinicians to uncover this sometimes subtle disorder. In the event, clinicians find themselves pulled in varying directions regarding the correct diagnosis of an emotionally dysregulated patient, consideration of cyclothymia should be paramount. In addition to emotional dysregulation, identification of oscillating levels of psychomotor activity, hypersensitivity, hyper-reactivity, and interpersonal dysfunction should hint towards a diagnosis of cyclothymia. This article will shed light on this misunderstood and often misdiagnosed disorder.[1] EtiologyThe suspected etiologies of bipolar disorders include genetic susceptibility, neurotransmitter dysregulation, and environmental triggers. Cyclothymia is thought to belong to this family of affective disorders and its etiology is regarded in kind.[2] Genetic factors have been robustly implicated in the etiology of cyclothymia. This influence is demonstrable by the concordance rate--57%--seen in monozygotic twins. Current genotypic studies are investigating several loci, including 18p11, 13q32, CLOCK genes, and ANK3.[2][3] Environmental factors play a large role in the development of bipolar disorders. Negative life events and negative cognitive styles are associated with an increased incidence of affective dysregulation and emotional instability.[3] EpidemiologyCyclothymia is associated with a lifetime prevalence of approximately 0.4%-1% and a male to female ratio of 1:1. Prevalence may increase in clinics with some surveys reporting rates as high as 5%.[2][3][4] PathophysiologyAs mentioned in the introduction, the phenomenology of cyclothymia overlaps with a multitude of separate disorders. One striking similarity is the emotional dysregulation observed in both cyclothymic patients and those with neurodevelopmental disorders.[5] These subsets of individuals have difficulty modulating their affect, suggesting a putative common neurophysiological aberration. Recent studies have determined that this commonality precipitates secondary to some deviance of the amygdala and fronto-limbic neural circuitry. This finding correlates with the observation that hyper-reactivity and regulatory deficits are associated with functional abnormalities of the amygdala and orbitofrontal cortex, respectively.[6][7] History and PhysicalThe essential characteristic of cyclothymia is a chronic, pervasive, fluctuating mood disturbance. These fluctuations are described as periods of distinguishable depressive and elevated episodes. Unlike conventional bipolar spectrum disorders, cyclothymia can induce spontaneous fleeting oscillations between euphoric and depressive dispositions. Depressive symptomatology may include depressed mood, irritability, hopelessness, helplessness, insomnia, fatigue, anhedonia, avolition, negativity of affect, headaches, neurasthenia, and suicidal ideation. Hypomanic symptoms consist of impulsivity, grandiosity, racing thoughts, increased sociability, excessive physical activity, and increased speech production. A developmental history will most likely reveal a chronic and pervasive pattern of emotional lability, hypersensitivity, recurrent interpersonal altercations, incidents of self-harming, episodes of excessive gambling, reckless sexual activity, multiple divorces, legal or financial problems, and recurrent job loss.[8][9] Less frequently, some will experience displacement of their distress and anxiety in the form of somatic pain. Such complaints include chest pain, asthenia, weight loss, hair loss, and headaches. EvaluationIn accordance with the propriety of the psychiatric evaluation, organicity should first be ruled out. [10]Thus, the clinician should order standard laboratory panels and indicated imaging studies to rule out any underlying etiology. Standard work-ups include a complete blood count, comprehensive metabolic profile, thyroid panel, vitamin B-12, folate, ammonia, urinalysis, and brain imaging. Toxic effects from iatrogenic sources, as well as illicit substances, can induce behavior resembling mania and/or depression, and thus drug screens and medication profiles are recommended. Once organic perturbations have been ruled out, a full psychiatric exam should be performed. This includes a history of present illness, psychiatric history, social history, substance use history, family psychiatric history, psychiatric review of symptoms, and mental status exam. Early work in defining this disorder was done by Hagop Akiskal. His validated questionnaires, the TEMPS-A and Cyclothymic-Hypersensitivity, have been translated into nearly 20 languages with research on several continents.[11][12] As mentioned in the introduction, cyclothymic symptomatology overlaps with manic, hypomanic, and depressive episodes, without meeting their full diagnostic threshold. Per DSM-5, cyclothymia is classified as the existence of symptomatology for the last two years, present for more days than not. Stability of mood cannot have exceeded any length of time longer than 2 consecutive months. The symptoms identified must have caused significant impairment in the patient's life. And lastly, the symptoms cannot be secondary to another psychiatric or medical illness. [13] Treatment / ManagementThe treatment of cyclothymia rests upon managing risk factors, recognizing early symptoms, and implementing appropriate interventions, including psychoeducation, pharmacotherapy, and counseling. The primary target of the aforementioned therapies should be focused on the pervasive underlying affective dysregulation. Psychoeducation is paramount and emphasizes the necessity of medication compliance, confidence in the doctor, acknowledging the interpersonal consequences of the maladaptive behavior patterns, and acceptance of the illness. To date, there are no approved FDA-recommended psychotropic medications for the treatment of cyclothymic disorder. In spite of this, there still remain viable alternatives in the management of this disorder. First-line psychotropic treatment of cyclothymia is the administration of a mood stabilizer--valproate if anxiety is dominant, lamotrigine if the anxious-depressive polarity is more prominent, and lithium for significant affective intensity. Some patients may benefit from the dual therapy of both lithium and lamotrigine.[6] Furthermore, atypical antipsychotics can be applied as a monotherapy or an adjunct in conjunction with a mood stabilizer. Current research recommends withholding the use of antidepressants in the setting of cyclothymia as it can exacerbate symptomatology. [1][9][14] In addition to pharmacotherapy and psychoeducation, cognitive-behavioral therapy (CBT) has shown the most robust evidence of psychotherapies in the setting of cyclothymia.[6] Moreover, treatment plans should be modified ad hoc, and not on some predetermined algorithm. Differential DiagnosisAs previously mentioned, deviant physiological states precipitating from organic etiologies can mimic symptoms of cyclothymia. Common abnormalities that can incite such symptomatology include endocrine diseases, autoimmune disorders, vitamin deficiencies, electrolyte abnormalities, infections, and traumatic brain injuries. Furthermore, iatrogenic causes can also induce manic and depressive-like symptoms, most notably steroids, levodopa, and antibiotics.[1][9] Lastly, intoxication and/or withdrawal of illicit substances almost always precipitate overlapping affective symptoms with cyclothymia. Thus, a thorough medical evaluation and work-up will help differentiate between organic and substance-related etiologies from primary psychiatric disorders. Once the primacy has been established, the clinician must then distinguish between psychiatric differentials. Cyclothymia shares many overlapping features with several psychiatric diagnoses. These include major depressive disorder, bipolar disorder type II, generalized anxiety disorder, neurodevelopmental disorders, and personality disorders. A detailed psychiatric evaluation will help the clinician to decipher between ambiguous presentations. Additionally, providers can administer psychiatric batteries for adjunctive and more objective assessments. Examples of assessment batteries include the Beck Depression Inventory, Beck Anxiety Inventory, Bipolar Spectrum Diagnostic Scale, and the My Mood Monitor (M-3) checklist.[14] PrognosisThe prognosis of cyclothymia is variable. Features of this disorder inherently make normative functioning almost untenable in the absence of appropriate psychiatric aid. The constellation of hypersensitivity, emotional dysregulation, impulsivity, emotional-reactivity, and limited self-efficacy leads to chronic interpersonal, professional, and intrapsychic difficulties. Prognosis varies by internal coping styles, personality factors, family support, and early initiation of medications and psychotherapy. Fortunately, the literature suggests that with sufficient support and resources those afflicted with cyclothymia can lead fulfilling lives with minimal perturbations.[1][15] ComplicationsComplications of this disorder are just as heterogeneous as its protean presentation. The severity of complications ranges from subtle iatrogenic side effects to suicide. The most common manifestations of complications include iatrogenic worsening of mood cyclicity and sequelae of emotional dysregulation, such as impulse control and substance use disorders. Less commonly, cyclothymia in youth can prove to be heterotypic, developing into bipolar disorder in adulthood.[1][2] Deterrence and Patient EducationThe importance of psychoeducation cannot be sufficiently emphasized in the setting of cyclothymia. Helping the patient to accept the existence of the disorder, adhere to the treatment plan, abstain from substance use, and develop crisis intervention strategies leads to a more beneficial prognosis. Furthermore, counseling should focus on assisting the patient to become more psychologically minded and to develop superior reflective capacities to more effectively regulate self-states and refrain from detrimental impulsivity. Ultimately, the patient ought to acknowledge the primacy of the disorder lies in their affective instability.[1] Enhancing Healthcare Team OutcomesManagement of cyclothymia, along with the rest of the bipolar disorders, often requires an interprofessional team approach, including the primary care clinician, psychiatrist, psychologist or social worker, as well as family and friends. Often this goes undiagnosed or misdiagnosed, which contributes to morbidity and mortality. Early consultation with psychiatry or inpatient hospitalization may be required if there are significant symptoms or if there is suicidality or progression to psychosis. The team must work together to achieve successful patient outcomes.[1] [Level 4] Review QuestionsReferences1.Perugi G, Hantouche E, Vannucchi G, Pinto O. Cyclothymia reloaded: A reappraisal of the most misconceived affective disorder. J Affect Disord. 2015 Sep 01;183:119-33. [PubMed: 26005206] 2.Scaini G, Valvassori SS, Diaz AP, Lima CN, Benevenuto D, Fries GR, Quevedo J. Neurobiology of bipolar disorders: a review of genetic components, signaling pathways, biochemical changes, and neuroimaging findings. Braz J Psychiatry. 2020 Sep-Oct;42(5):536-551. [PMC free article: PMC7524405] [PubMed: 32267339] 3.Howland RH, Thase ME. A comprehensive review of cyclothymic disorder. J Nerv Ment Dis. 1993 Aug;181(8):485-93. [PubMed: 8360639] 4.Van Meter AR, Youngstrom EA, Findling RL. Cyclothymic disorder: a critical review. Clin Psychol Rev. 2012 Jun;32(4):229-43. [PubMed: 22459786] 5.Ruocco AC, Amirthavasagam S, Choi-Kain LW, McMain SF. Neural correlates of negative emotionality in borderline personality disorder: an activation-likelihood-estimation meta-analysis. Biol Psychiatry. 2013 Jan 15;73(2):153-60. [PubMed: 22906520] 6.Perugi G, Hantouche E, Vannucchi G. Diagnosis and Treatment of Cyclothymia: The "Primacy" of Temperament. Curr Neuropharmacol. 2017 Apr;15(3):372-379. [PMC free article: PMC5405616] [PubMed: 28503108] 7.Domes G, Schulze L, Herpertz SC. Emotion recognition in borderline personality disorder-a review of the literature. J Pers Disord. 2009 Feb;23(1):6-19. [PubMed: 19267658] 8.Baldessarini RJ, Vázquez GH, Tondo L. Bipolar depression: a major unsolved challenge. Int J Bipolar Disord. 2020 Jan 06;8(1):1. [PMC free article: PMC6943098] [PubMed: 31903509] 9.Miklowitz DJ, Johnson SL. The psychopathology and treatment of bipolar disorder. Annu Rev Clin Psychol. 2006;2:199-235. [PMC free article: PMC2813703] [PubMed: 17716069] 10.Qiu F, Akiskal HS, Kelsoe JR, Greenwood TA. Factor analysis of temperament and personality traits in bipolar patients: Correlates with comorbidity and disorder severity. J Affect Disord. 2017 Jan 01;207:282-290. [PMC free article: PMC5107122] [PubMed: 27741464] 11.Jović J, Hinić D, Ćorac A, Akiskal HS, Akiskal K, Maremmani I, Popović D, Ristić-Ignjatović D. The Development of Temperament Evaluation of Memphis, Pisa, Paris, and San Diego - Auto-questionnaire for Adolescents (A-TEMPS-A) in a Serbian Sample. Psychiatr Danub. 2019 Sep;31(3):308-315. [PubMed: 31596823] 12.Perugi G, Del Carlo A, Benvenuti M, Fornaro M, Toni C, Akiskal K, Dell'Osso L, Akiskal H. Impulsivity in anxiety disorder patients: is it related to comorbid cyclothymia? J Affect Disord. 2011 Oct;133(3):600-6. [PubMed: 21665290] 13.Kaltenboeck A, Winkler D, Kasper S. Bipolar and related disorders in DSM-5 and ICD-10. CNS Spectr. 2016 Aug;21(4):318-23. [PubMed: 27378177] 14.Hankin BL. Etiology of Bipolar Disorder Across the Lifespan: Essential Interplay With Diagnosis, Classification, and Assessment. Clin Psychol (New York). 2009 Jun 10;16(2):227-230. [PMC free article: PMC2908423] [PubMed: 20657707] 15.Jones FD. Cyclothymia and the kindling hypothesis. Am J Psychiatry. 1990 Jun;147(6):818-9. [PubMed: 2343938] Is the key feature of cyclothymia?Cyclothymia causes emotional ups and downs, but they're not as extreme as those in bipolar I or II disorder. With cyclothymia, you experience periods when your mood noticeably shifts up and down from your baseline. You may feel on top of the world for a time, followed by a low period when you feel somewhat down.
Who is most likely to be diagnosed with cyclothymia?It is estimated that the rate of occurrence of cyclothymia in the general population is between 0.4% to 1%, with it equally affecting men and women. Women, however, are more likely to seek treatment. While typical onset of the disorder occurs during adolescence, its onset is consistently hard to identify.
How do you assess for cyclothymia?A: There is no test to see if you have cyclothymic disorder. If you think you might have the condition, your doctor will talk to you about your mood history and make an assessment. You may be referred to a psychiatrist if necessary.
What is the diagnostic criteria for cyclothymic disorder?Diagnostic criteria
You've had many periods of elevated mood (hypomanic symptoms) and periods of depressive symptoms for at least two years (one year for children and teenagers) — with these highs and lows occurring during at least half that time. Periods of stable moods usually last less than two months.
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