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History

In 1882, Karl Ludwig Kahlbaum identified a disorder characterized by recurring mood cycles. The disorder contained both melancholic and manic episodes that occurred in a milder form than in bipolar disorder. This condition was coined “cyclothymia” by Kahlbaum and his student Ewald Hecker. Kahlbaum developed his theory of cyclothymia through his work with patients presenting with these symptoms at the Kahlbaum Sanitarium in Goerlitz, Silesia (Germany). He was recognized as a leading hypnotherapist and psychotherapist of his day. He was a progressive in the field of mental health, believing that mental illness should not carry a stigma and that patients dealing with mental health issues should be treated humanely.

Cyclothymia, known today as cyclothymic disorder, tends to be underdiagnosed due to its low intensity Kalhbaum was the first to recognize that cyclothymic patients often do not seek help for the disorder due to its mild symptoms. The exact prevalence rates for cyclothymia have not been widely studied. Some studies estimate the lifetime prevalence rate to be between 5 and 8% whereas other studies suggest a much lower rate, ranging from 0.4 to 2.5%. Cyclothymia is more common among women than men. Cyclothymia is diagnosed in around fifty percent of patients with depression who are evaluated in psychiatric outpatient settings. Despite its identification over 100 years ago, cyclothymia has not been a focus in psychiatry or psychology since its inception as a disorder. According to Perugi and colleagues (2015), it has received the least attention of all the mood disorders.

Cyclothymia has been conceptualized in a variety of ways, including as a subtype of bipolar disorder, a temperament, a personality trait, and a personality disorder. There is also an argument that cyclothymia should be considered a neurodevelopmental disorder. The two defining features of the disorder, according to DSM-5, are the presence of depressive episodes and hypomania. Cyclothymia is also classified as a subtype of bipolar disorder in DSM-5, but some researchers disagree with this classification and argue that it should be primarily defined as an exaggeration of mood and emotional instability. In the past, cyclothymia has been conceptualized to include other characteristics in addition to the flux between depression and hypomania, such as mood reactivity, impulsivity, and anxiety.

DSM-5 Criteria

Cyclothymia is classified in DSM-5 as a subtype of bipolar disorder. The criteria are:

1. Periods of elevated mood and depressive symptoms for at least half the time during the last two years for adults and one year for teenagers.
2. Periods of stable moods last only two months at most.
3. Symptoms create significant problems in one or more areas of life.
4. Symptoms do not meet the criteria for bipolar disorder, major depression, or another mental disorder.
5. Symptoms are not caused by substance use or a medical condition.

The DSM-5 criteria for cyclothymia are restrictive according to some researchers. This affects the diagnosis of cyclothymia because less patients get diagnosed than potentially could. This means that a patient who has some symptoms of the disorder might not be able to get treatment because they do not meet all of the necessary criteria described in DSM-5. Furthermore, it also leads to more attention being placed on depression and other bipolar-spectrum disorders because if a patient does not meet all the criteria for cyclothymia they are often given a depression or bipolar spectrum diagnosis. Improper diagnosis may lead some patients with cyclothymia to be treated for a comorbid disorder rather than having their cyclothymic tendencies addressed.

Symptoms

Patients with cyclothymia experience both depressive phases and hypomanic phases (which are more mild than classic manic phases). The depressive and manic symptoms in cyclothymia last for variable amounts of time due to the unstable and reactive nature of the disorder. The depressive phases are similar to major depressive disorder and are characterized by dulled thoughts and sensations and the lack of motivation for intellectual or social activities. Most patients are generally fatigued and tend to sleep frequently and for long periods of time. However, other patients experience insomnia. Other symptoms of cyclothymic depression include indifference toward people or activities that used to be extremely important. Cyclothymic depression also leads to difficulty making decisions. In addition, patients tend to be critical and complain easily about anything and everything. Suicidal thoughts are common and must be taken seriously, even in mild forms of cyclothymia. In the depressive state, people with cyclothymia also experience physical complaints including frequent headaches, tightness in the head and chest, an empty sensation in the head, weakness, weight loss, and hair loss.

The distinguishing factor between typical depression and cyclothymic depression is that in cyclothymic depression, the patient also experiences hypomania. Patients with cyclothymia can switch from the depressive state to the hypomanic state without warning to them or others. The duration of phases is unpredictable and is unique to each patient. Some patients can cycle through a phase each day, while others have episodes that last months. These phases are not always uniform in length.

According to Koukopoulos (2003), patients’ enthusiasm for life increases dramatically in the hypomanic state. Their thoughts become faster and the person becomes more sociable and talkative. Although patients’ ability to criticize the world around them becomes even stronger than in the depressive state, they also become more compassionate and are inclined to help others, by for example participating in volunteer work. Patients tend to develop friendlier attitudes, often becoming more chatty than usual and even engaging in conversation with strangers. Patients in the hypomanic state also become restless and occupy themselves in much more activity, often with greater capacity for this than in the depressive or healthy states. For example, patients without musical interest or talent have been observed to sing with more enthusiasm and a better tone of voice. Finally, the hypomanic state brings symptoms that are characteristic of the general manic state as well. Patients engage in spending sprees, spontaneous actions, have heightened self-esteem, and greater vanity. In contrast to a regular manic state that would be associated with bipolar I, symptoms in the hypomanic phase generally occur in a less severe form. However, this does not mean that they are any less difficult to deal with or pervasive in the patients’ lives.

Comorbidity

Cyclothymia commonly occurs in conjunction with other disorders. Research indicates that 20-50 percent of people with depression, anxiety, and related disorders also have cyclothymia. According to Perugi and colleagues, when people with cyclothymia seek mental health resources it tends to be for symptoms of their comorbid condition rather than for their symptoms of cyclothymia. In children and adolescents, the most common comorbidities with cyclothymia are anxiety disorders, impulse control issues, eating disorders, and ADHD. In adults, cyclothymia also tends to be comorbid with impulse control issues. Sensation-seeking behaviors occur in hypomanic states. These often include gambling and compulsive sexuality in men, or compulsive buying and binge eating in women. Cyclothymia is also associated with drug abuse and addiction. For example, it often occurs with alcoholism. A further complication of this comorbidity is that cyclothymia can exasperate symptoms for those who are alcohol-dependent.

In addition to sensation-related disorders, cyclothymia has also been associated with atypical depression. In one study, a connection was found between interpersonal sensitivity, mood reactivity, and cyclothymic mood swings, all of which are symptoms of atypical depression. Cyclothymia also tends to occur in conjunction with separation anxiety, where a person has anxiety as a result of separation from a caregiver, friend, or loved one. Other issues that tend to co-occur with cyclothymia include social anxiety, fear of rejection and a tendency toward hostility to those connected with past pain and rejection. People with cyclothymia tend to seek intense interpersonal relationships when in a hypomanic state and isolation when in a depressed state. This generally leads to short, tumultuous relationships. Patients can experience dissociative experiences as well. In one study, patients with a cyclothymic temperament scored higher on the Dissociative Experience Scale (DES) than patients who did not have a cyclothymic temperament.

Treatment and Prognosis

Cyclothymia is often not recognized by the affected individual or medical professionals due to its ostensibly mild symptoms. In addition, it is difficult to identify and classify. Due to disagreement and misconceptions among health and mental health professionals, cyclothymia is often diagnosed as "bipolar not otherwise specified." Cyclothymia is also often confused with borderline personality disorder due to their similar symptoms, especially in older adolescents and young adults. Most patients suffering from the disorder present in a depressive state, not realizing that their hypomanic states are abnormal. Mild manic episodes tend to be interpreted as part of the person’s personality or simply a heightened mood. In addition, the disorder often manifests during childhood or adolescence, making it even more difficult for patients to distinguish between symptoms of the disorder and their personality. For example, patients may think that they just suffer from mood swings and not realize that these are a result of a psychiatric condition. Furthermore, lack of awareness of hypomanic episodes makes cyclothymia easy to confuse with unipolar depression, in which a patient would experience only depressive episodes.

Many clinicians do not accept the cyclothymia diagnosis and do not use it. Cyclothymia is difficult to treat, mainly because of the lack of agreement about its definition and its diagnostic difficulty. Furthermore, there is a lack of research on treating patients with cyclothymia. This leads to a long diagnostic delay for cyclothymic patients. Over half of patients with cyclothymia wait more than ten years for a correct diagnosis. However, some treatment protocol has been developed. The primary focus when treating cyclothymia should be minimizing the mood instability and emotional reactivity of the patient. Research suggests that cyclothymia should be treated as if it is a bipolar spectrum disorder.

The CTAH team in Paris, France has developed a treatment that consists of six two-hour group sessions. These sessions have the following characteristcs, as described by Hantouche and Perugi (2012):

1. Session 1: characteristics of case, causes, and medications discussed.
2. Session 2: mood swings monitored, warning signs determined, strategies developed to deal with early relapses, beneficial routines created.
3. Sessions 3 and 4: psychological weaknesses evaluated (including emotional dependency, sensitivity to rejection, excessive need to please, testing limits, need for control and compulsive behaviors).
4. Session 5: cognitive processes linked to highs and lows discussed.
5. Session 6: interpersonal conflicts considered.

(adapted from Hantouche and Perugi (2012))

Cognitive Behavior Therapy (CBT) is also considered potentially effective for patients diagnosed with cyclothymia. Totterdell, Kellett, and Mansell (2012) found that CBT administered in 19 sessions over 35 weeks could give those with cyclothymia increased control over thoughts. This study suggests that CBT may be effective for treating cyclothymia, but further research is needed as it was a single-case design and therefore difficult to generalize to a larger population.

Medication can be used in addition to behavioral approaches. However, mood stabilizers should be used before antidepressants, and if antidepressants are used they should be used with caution. Antidepressants are a concern due to the possibility of inducing hypomanic switches or rapid cycling. Hypomanic switches occur when a patient suddenly switches from a depressed state to a hypomanic state or vice versa, and rapid cycling is the recurrent cycle of this switch. This unpredictable cycle creates irregularity in the patient’s mood, and they enter into extreme states that are not optimal. This further exasperates the cycle of cyclothymia.

Prognosis for patients with cyclothymia is relatively unknown. Longitudinal studies are needed to further understand the course of this and other related disorders, but they have not been done due to the limited attention placed on cyclothymia in research and clinical practice. Patients with cyclothymia or a cyclothymic temperament are thought to be at risk for developing a more severe form of bipolar disorder. An estimated one third of children with cyclothymia eventually develop bipolar I or bipolar II. Onset of cyclothymia typically occurs in adolescence, and it is thought to be most prevalent in youth. It probably first occurs earlier than other childhood disorders. However, this is controversial, as are bipolar disorders in general when discussing the pediatric population.

Cyclothymia has been seen to have a genetic component, as well as a genetic link with bipolar disorder. People with bipolar disorder and their family members have higher rates of cyclothymic temperament. In one study of children whose parents had bipolar I, one quarter met the criteria for cyclothymia.