Discussion: Cyclothymic Disorder

Discussion: Cyclothymic Disorder

Discussion: Cyclothymic Disorder

Patients with cyclothymic disorder (CD) are chronically either elated or depressed, but for the first couple of years, they do not fulfill criteria for a manic, hypomanic, or major depressive episode. Note that there’s a phrase back there dripping with italics. I’ll explain in the sidebar below.

Cyclothymic disorder was at one time regarded as a personality disorder. This may have been partly due to the fact that it begins so gradually and lasts such a long time. Articles in the literature still refer to cyclothymic temperament, which may be a precursor to bipolar disorders.

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The clinical appearance can be very variable. Some patients are nearly always dysphoric, occasionally shifting into hypomania for a day or so. Others can shift several times in a single day. Often the presentation is mixed.

Typically beginning gradually in adolescence or young adulthood, CD affects under 1% of the general population. However, clinicians diagnose it even less often than you’d expect. The sex distribution is about equal, though women are more likely to come for treatment. Not surprisingly, patients usually only come to clinical attention when they are depressed. Once begun, it tends toward chronicity.

What if your cyclothymic patient later develops a manic, hypomanic, or major depressive episode? In that case, you’ll have to change the diagnosis to something different. Once a major mood episode rears its head, that patient can never revert to CD. If the new episode is major depressive, then you’ll probably fall back on an unspecified (or other specified) bipolar disorder, inasmuch as, by definition, the “up” periods of CD will not qualify as a hypomanic episode. Note that this is a change from DSM-IV, which allowed a diagnosis of a bipolar disorder along with CD.

Essential Features of Cyclothymic Disorder

The patient has had many ups and downs of mood that don’t meet criteria for any of the mood episodes (major depressive, hypomanic, manic). Although symptoms occur most of the time, as much as a couple of months of level mood can go by.

The Fine Print

The D’s: • Duration (2+ years; 1+ year in children and adolescents) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, other bipolar disorders)

Coding Notes

Specify if: With anxious distress.

Honey Bare

“I’m a yo-yo!”

Without her feathers and sequins, Honey Bare looked anything but provocative. She had begun life as Melissa Schwartz, but she loved using her stage name. The stage in question was Hoofer’s, one of the bump-and-grind joints that thrived near the waterfront. The billboard proclaimed that it was “Only a Heartthrob Away” from the Navy recruiting station. Since she’d dropped out of college 4 years earlier, Honey had been a front-liner in the four-girl show at Hoofer’s. Every afternoon on her way to work she passed right by the mental health clinic, but this was her first visit inside.

“In our current gig, I play the Statue of Liberty. I receive the tired, the poor, and the huddled masses. Then I take off my robes.”

“Is that a problem?” the interviewer wanted to know.

Most of the time, it wasn’t. Honey liked her little corner of show biz. When the fleet was in, she played to thunderous applause. “In fact, I enjoy just about everything I do. I don’t drink much, and I never do drugs, but I go to parties. I sing in our church choir, go to movies—I enjoy art films quite a bit.” When she felt well, she slept little, talked a lot, started a hundred projects, and even finished some of them. “I’m really a happy person—when I’m feeling up.”

But every couple of months, there’d be a week or two when Honey didn’t enjoy much of anything. She’d paste a smile on her face and go to work, but when the curtain rang down, the smile came off with her makeup. She was never suicidal, and her sleep and appetite didn’t suffer; her energy and concentration were normal. But it was as if all the fizz had gone out of her ginger ale. She could see no obvious cause for her mood swings, which had been going on for years. She could count on the fingers of both hands the number of weeks she had been “just normal.”

Lately, Honey had acquired a boyfriend—a chief petty officer who wanted to marry her. He said he loved her because she was so vivacious and enthusiastic, but he had only seen her when she was bubbly. Always before, when she was depressed, he had been out to sea. Now he had written that he was being transferred to shore duty, and she feared it would be the end of their relationship. As she said it, two large tears trickled through the mascara and down her cheeks.

Four months and several visits later, Honey was back, wearing a smile. The lithium carbonate, she reported, seemed to be working well. The peaks and valleys of her moods had smoothed out to rolling hills. She was still playing the Statue of Liberty down at Hoofer’s.

“My sailor’s been back for nearly 3 months,” she said, “and he’s still carrying the torch for me.”

As far back as the mid-19th century, Karl Kahlbaum—the German psychiatrist who first described catatonia—noted that some people experience frequent alterations between highs and lows so mild as not to require any treatment. His observations were confirmed and extended by his student and colleague, Ewald Hecker (who was best known for his description of hebephrenic schizophrenia).

But by the mid-20th century, the first DSM described cyclothymia as a cardinal personality type (along with schizoid, paranoid, and inadequate personalities). The description actually sounds pretty wonderful: “an extratensive and outgoing adjustment to life situations, an apparent personal warmth, friendliness and superficial generosity, an emotional reaching out to the environment, and a ready enthusiasm for competition.” (I’ll leave the looking-up of extratensive as an extra-credit exercise.) Anyway, thus was born cyclothymia as a temperament or personality style.

DSM-II kept cyclothymic personality with the other personality disorders, but in 1980 it was moved to the mood disorders and rechristened with its current name. However, its relationship to other mood disorders is fraught; experts argue about it even today. Many hold that it can be prodromal to a more severe bipolar disorder. Some point out the similarities between cyclothymia and borderline personality disorder (labile, irritable moods leading to interpersonal conflict), even suggesting that the latter disorder belongs on the bipolar spectrum—a speculation extreme enough to invite resistance.

All of this suggests that we still have work to do in determining cyclothymic disorder’s exact place in the diagnostic firmament. Though the DSM-5 criteria are a step along the road to differentiation of this venerable diagnosis, they may not signify any real progress.

Evaluation of Honey Bare

The first and most obvious question is this: Had Honey ever fulfilled criteria for a manic, hypomanic, or major depressive episode (cyclothymic disorder criterion C)? When feeling down, she had no vegetative symptoms (problems with sleep or appetite) of major depressive episode. She had normal concentration, had never been suicidal, and did not complain of feeling worthless. At the other pole, she did indeed have symptoms similar to those of hypomania (talkative, slept less, was more active than at other times), but they weren’t even severe enough for hypomania. Honey’s “up” moods weren’t elevated (or irritable, or expansive) to an abnormal extent (hypomanic episode criterion A)—they were her normal functioning. Furthermore, she had experienced far more cycles than would be typical for bipolar II disorder. We can therefore rule out any other bipolar or major depressive diagnosis.

Honey testified that she was either up or down most of the time (we’re back to cyclothymia—criterion B). Because she was never psychotic, she could not qualify for a diagnosis such as schizoaffective disorder (D). She didn’t use drugs or alcohol, ruling out a substance-induced mood disorder (E). Again, bipolar I, bipolar II, and major depressive disorders are ruled out due to the lack of relevant episodes. (However, because they involve so many swings of mood, either bipolar I or II with rapid cycling can sometimes be confused with cyclothymic disorder.) Mood shifts, impulsivity, and interpersonal problems can of course be found aplenty in borderline personality disorder, but we’d never diagnose a personality disorder when a major mental diagnosis was available.

Symptoms that were present much of the time would qualify Honey for CD. She had many mood swings; only infrequently was her mood neither high nor low. The only specifier allowed with CD, with anxious distress, didn’t to me seem relevant to Honey’s symptoms. With a GAF score of 70 on admission and 90 at follow-up, her diagnosis would be simple:

Discussion: Cyclothymic Disorder Discussion: Cyclothymic Disorder