Cyclothymia ... Anxiety, Depression, Stress

Cyclothymia is a condition which causes mild hypomanic and depressive episodes. It is defined in the bipolar spectrum. Specifically, this disorder is a milder form of bipolar II disorder consisting of recurrent mood disturbances between hypomania and dysthymic mood. A single episode of hypomania is sufficient to diagnose cyclothymic disorder; however, most individuals also have dysthymic periods. The diagnosis of cyclothymic disorder is not made when there is a history of mania or major depressive episode or mixed episode. The lifetime prevalence of cyclothymic disorder is 0.4-1%. The rate appears equal in men and women, though women more often seek treatment. Unlike some forms of bipolar disorder (specifically, bipolar I disorder), people with cyclothymia are almost always fully functioning.

Cyclothymia is similar to bipolar II disorder in that it presents itself in signature hypomanic episodes. Because hypomania is often associated with incredibly creative, outgoing, and high-functioning behavior, both conditions are often undiagnosed. Typically, like most of the disorders in the bipolar spectrum, it is the depressive phase that leads most sufferers to get help.

Diagnostic criteria

DSM-IV-TR
During the first two years of the disorder, the patient has not experienced enough symptoms to be identified having either a bipolar disorder (I or II) or major depressive disorder.
Symptoms must be present for at least two years with periods of hypomania and periods of low mood that do not fulfill the criteria for major depressive disorder.
The longest period the patient has been free of symptoms is two months.
The disorder cannot be better explained as schizoaffective disorder, and it is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder or a psychotic disorder not otherwise specified (NOS).
Symptoms are not directly caused by a general medical condition or the use of any substances such as prescription or unprescribed medication/street drugs.
The symptoms cause the patient significant distress. They impair work, social or personal functioning.
A person with this disorder may experience euphoric highs, boosts of energy and require less sleep. This hypomanic period may be followed by a severe mood swing leading into a serious depressive episode.

ICD-10
A persistently unstable mood, involving many periods of mild depression and mild elation. This instability usually develops in late adolescence and follows a chronic course, although moods may be within norms for months at a time. Mood swings are usually perceived by the individual as being unrelated to life events. The diagnosis is difficult to establish without a prolonged period of observation or an unusually good account of the individual's past behaviour. Because the mood swings are relatively mild and the episodes of mood elevation may be enjoyable, cyclothymia frequently fails to come to medical attention. In some cases this may be because the mood change, although present, is less prominent than cyclical changes in activity, self-confidence, sociability, or appetitive behaviour. If required, age of onset may be specified as early (in late teenage or the twenties) or later.

The essential feature is a persistent instability of mood, involving numerous periods of mild depression and mild elation, none of which has been sufficiently severe or prolonged to fulfill the criteria for bipolar disorder or recurrent depressive disorder. This implies that individual episodes of mood swings do not fulfill the criteria for any of the categories described under manic episode or major depressive episode.

Differential diagnosis
This disorder is common in the relatives of patients with bipolar disorder and some individuals with cyclothymia eventually develop bipolar disorder themselves. It may persist throughout adult life, cease temporarily or permanently, or develop into more severe mood swings meeting the criteria for bipolar disorder or recurrent depressive disorder in rare cases.

Symptoms

Dysthymic phase

Difficulty making decisions; problems concentrating; poor memory recall; guilt; self-criticism; low self-esteem; pessimism; self-destructive thinking; continuously feeling sad; apathy; hopelessness; helplessness; irritability; quick temper; lack of motivation; social withdrawal; appetite change; lack of sexual desire; self-neglect; fatigue or insomnia

Euphoric phase

Unusually good mood or cheerfulness (euphoria); Extreme optimism; Inflated self-esteem; Poor judgment; Rapid speech; Racing thoughts; Aggressive or hostile behavior; Being inconsiderate of others; Agitation; Increased physical activity; Risky behavior; Spending sprees; Increased drive to perform or achieve goals; Increased sexual drive; Decreased need for sleep; Tendency to be easily distracted; Inability to concentrate

Biological

Family
One is 2-3 times more likely to have the disorder if someone in the immediate family has it or if an identical twin has it. In a study by Bertelsen, Harvard, and Huage (1977), if an identical twin had depression 59% of the identical twins had it also.

Gender
Heritability for women ranges from 36-44%; for men, 18-24%.

Genes
The same genes may contribute to depression and anxiety.

Serotonin
Serotonin regulates other hormones like norepinephrine and dopamine, so when serotonin is low the other chemicals may fluctuate, causing irritability, impulsivity and mood irregularities such as dysthymia and depression.

Cortisol
depressed individuals can have high cortisol levels. Cortisol is a stress hormone, and mood disorders often occur during stressful points in one’s life. Elevated stress hormones can affect functioning of the hippocampus, an important centre for memory and cognitive processes. Overproducing cortisol can also impair the brain’s ability to regenerate neurons in the hippocampus.

Psychological
Stressful events, as perceived by the individual
Job loss, relationship failure, identity change, natural disaster, learned helplessness and hopelessness, extreme feelings, negative thinking patterns.

Social

Environment
Influences the disorder 60-80% of the time.

Treatment
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Exercise
It has been repeatedly demonstrated that regular, vigorous physical exercise can help with mood regulation and emotional stability.

Medications
Lithium, a mood stabilizer
Anti-seizure medication/anticonvulsants (e.g., valproic acid, divalproex, and lamotrigine) are options.
Seroquel

Therapy
Cognitive behavioural therapy (CBT)
Interpersonal psychotherapy (IT)
Group therapy
Integrative Therapy
Psychodynamic Therapy