Cyclothymic Disorder

Cyclothymic Disorder

Cyclothymic Disorder

Primer

Cyclothymic disorder is a mood disorder characterized by chronic, fluctuating mood disturbances that consist of numerous hypomanic symptoms (not a hypomanic episode) and depressive symptoms (not a depressive episode), that are chronologically distinct from each other. It is best conceptualized as “mild” form of bipolar II disorder.^[1]

Epidemiology

The lifetime prevalence of cyclothymic disorder is approximately 0.4% to 1%.^[2]
- The prevalence in mood disorders clinics may range from 3% to 5%
Despite these relatively high estimated prevalence rates, cyclothymic disorder is rarely diagnosed in clinical practice.^[3]
In the general population, cyclothymic disorder is apparently equally common in males and females. In clinical settings, females are more likely to present for clinical attention.
More females are diagnosed than males (3:2 ratio).^[4]

Prognosis

Cyclothymic disorder begins in adolescence or early adulthood, with an insidious onset and persistent course.^[5]
There is a 15 to 50% chance that an individual with cyclothymic disorder will subsequently develop bipolar I or bipolar II disorder.^[6]

Comorbidity

Between 10 to 20% of individuals with borderline personality disorder are estimated to also meet criteria for cyclothymic disorder (though this is not formally diagnosed).^[7]
Substance use disorders, and sleep disorders can be common. Children diagnosed with cyclothymic disorder are also more likely have comorbid attention-deficit/hyperactivity disorder.^[8]

Risk Factors

Major depressive disorder, bipolar I disorder, and bipolar II disorder are more common among biological first-degree relatives of individuals with cyclothymic disorder.^[9]
About 30% of all individuals with cyclothymic disorder have a family history of bipolar I disorder.^[10]

DSM-5 Diagnostic Criteria

There is a debate about whether cyclothymic disorder should better be conceptualized as a temperamental predisposition instead of a true mental disorder. See also: Parker, G., McCraw, S., & Fletcher, K. (2012). Cyclothymia. Depression and anxiety, 29(6), 487-494.

Criterion A

For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.

Criterion B

During the above 2 year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.

Criterion C

Criteria for a major depressive, manic, or hypomanic episode have never been met.

Criterion D

The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

Criterion E

The symptoms are not attributable to the physiological effects of a substance (e.g. - a drug of abuse, a medication) or another medical condition (e.g. - hyperthyroidism).

Criterion F

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specifiers

With anxious distress

At least 2 of the following symptoms during the majority of days of the current or most recent episode of mania, hypomania, or depression:
- (1) Feeling keyed up or tense
- (2) Feeling unusually restless
- (3) Difficulty concentrating because of worry
- (4) Fear that something awful may happen
- (5) Feeling that the individual might lose control of himself or herself
Severity:
- Mild: 2 symptoms
- Moderate: 3 symptoms
- Moderate-severe: 4 or 5 symptoms
- Severe: 4 or 5 symptoms and with motor agitation

Note: Anxious distress has been noted as a prominent feature of both bipolar and major depressive disorder in both primary care and specialty mental health settings. High levels of anxiety have been associated with higher suicide risk, longer duration of illness, and greater likelihood of treatment nonresponse. As a result, it is clinically useful to specify accurately the presence and severity levels of anxious distress for treatment planning and monitoring of response to treatment.

Screening and Rating Scales

Psychometric Scales for Bipolar Disorder

Name	Rater	Description	Download
Young Mania Rating Scale (YMRS)	Clinician	Most frequently utilized to assess manic symptoms. 11 items on the patient’s subjective report over the last 48 hours plus clinical observations.^[11] Takes 15–30 minutes to complete.	YMRS Download
Mood Disorder Questionnaire (MDQ)	Patient	The MDQ screens for bipolar spectrum disorder, (which includes Bipolar I, Bipolar II and unspecified bipolar disorder). There are 13 self-rated questions. Although the original study claimed a 90% specificity and 70% sensitivity for an eventual diagnosis of bipolar disorder, more recent studies show that the MDQ risks falsely identifying individuals with bipolar disorder.^[12]^[13]^[14] For example, borderline personality disorder, PTSD, substance use disorder, and childhood abuse are associated with false positives on the MDQ. More recent studies have shown that the positive predictive value of the MDQ is only around 55%.^[15]	MDQ Download

Pathophysiology

The pathophysiology of cyclothymic disorder is not well understood. Given its connection to bipolar disorder, there may be similar underlying mechanisms.

Differential Diagnosis

Bipolar and related disorder due to another medical condition and depressive disorder due to another medical condition
- The diagnosis of bipolar and related disorder due to another medical condition or depressive disorder due to another medical condition is made when the mood disturbance is judged to be attributable to the physiological effect of a specific, usually chronic medical condition (e.g. - hyperthyroidism). This determination is based on the history, physical examination, or laboratory findings. If it is judged that the hypomanic and depressive symptoms are not the physiological consequence of the medical condition, then the primary mental disorder (i.e. - cyclothymic disorder) and the medical condition are diagnosed.
- For example, this would be the case if the mood symptoms are considered to be the psychological (not physiological) consequence of having a chronic medical condition, or if there is no etiological relationship between the hypomanic and depressive symptoms and the medical condition.
Substance/medication-induced bipolar and related disorder or substance/medication-induced depressive disorder
- Substance/medication-induced bipolar and related disorder and substance/medication-induced depressive disorder are distinguished from cyclothymic disorder by the clinical judgment that a substance/medication (especially stimulants) is etiologically related to the mood disturbance. The frequent mood swings in these disorders that are suggestive of cyclothymic disorder usually resolve following cessation of substance/medication use.

Bipolar I disorder, with rapid cycling, and bipolar II disorder, with rapid cycling
- Both disorders may resemble cyclothymic disorder due to frequent marked shifts in mood. By definition, in cyclothymic disorder, the criteria for a major depressive, manic, or hypomanic episode has never been met. contrast this with the bipolar I disorder and bipolar II disorder specifier “with rapid cycling” which requires that full mood episodes be present.
Borderline personality disorder
- Borderline personality disorder is associated with marked shifts in mood that may suggest cyclothymic disorder. If the criteria are met for both disorders, both borderline personality disorder and cyclothymic disorder can be diagnosed.
Other Specified Bipolar and Related Disorders

Investigations

As clinically indicated.

Treatment

There remains limited research on treatments for cyclothymic disorder.

Medications

Mood stabilizers are typically considered the primary treatment for cyclothymic disorder.^[16] Dosages are usually similar to that used in the treatment of bipolar I disorder. The use of antidepressants should be cautioned, however, because individuals have an increased risk for antidepressant-induced hypomania or mania (and hence a subsequent diagnosis of bipolar disorder).^[17] Close to 50% of all individuals with cyclothymic disorder treated with antidepressants will experience an antidepressant-induced episode of mania or hypomania.

Psychotherapy

Psychotherapy involves education about their diagnosis, and the developing coping strategies for mood fluctuations. Family group therapy may be helpful as well and identifying early warning signs of symptoms of mania is also important. No specific forms of therapy have been specifically studied in cyclothymic disorder.

Guidelines

Resources

Research

Van Meter, A. R., Youngstrom, E. A., & Findling, R. L. (2012). Cyclothymic disorder: a critical review. Clinical psychology review, 32(4), 229-243.

¹⁾ Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry (Eleventh edition.). Philadelphia: Wolters Kluwer.

²⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

³⁾ Van Meter, A. R., Youngstrom, E. A., & Findling, R. L. (2012). Cyclothymic disorder: a critical review. Clinical psychology review, 32(4), 229-243.

⁴⁾ Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry (Eleventh edition.). Philadelphia: Wolters Kluwer.

⁵⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

⁶⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

⁷⁾ Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry (Eleventh edition.). Philadelphia: Wolters Kluwer.

⁸⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

⁹⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

¹⁰⁾ Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry (Eleventh edition.). Philadelphia: Wolters Kluwer.

¹¹⁾ Young, R. C., Biggs, J. T., Ziegler, V. E., & Meyer, D. A. (1978). A rating scale for mania: reliability, validity and sensitivity. The British Journal of Psychiatry, 133(5), 429-435.

¹²⁾ Paterniti, S., & Bisserbe, J. C. (2018). Factors associated with false positives in MDQ screening for bipolar disorder: Insight into the construct validity of the scale. Journal of affective disorders, 238, 79-86.

¹³⁾ Hirschfeld, R. M., Holzer, C., Calabrese, J. R., Weissman, M., Reed, M., Davies, M., ... & Tierce, J. (2003). Validity of the mood disorder questionnaire: a general population study. American Journal of Psychiatry, 160(1), 178-180.

¹⁴⁾ Hirschfeld, R. M., Williams, J. B., Spitzer, R. L., Calabrese, J. R., Flynn, L., Keck Jr, P. E., ... & Zajecka, J. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. American journal of psychiatry, 157(11), 1873-1875.

¹⁵⁾ Paterniti, S., & Bisserbe, J. C. (2018). Factors associated with false positives in MDQ screening for bipolar disorder: Insight into the construct validity of the scale. Journal of affective disorders, 238, 79-86.

¹⁶⁾ Perugia, G., Hantouchec, E., & Vannucchia, G. (2017). Diagnosis and treatment of cyclothymia: the “primacy” of temperament. Current neuropharmacology, 15(3), 372-379.

¹⁷⁾ 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.

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