What is Cyclothymia?
Glossary
The following brief glossary is intended to provide you with a basic understanding of the various terms associated with Cyclothymic Disorder.
Bipolar Disorder - A mood disorder that involves fluctuations between full blown Mania and Major Depression, where the patient experiences no neutral states without treatment.
Euthymic State - A normal or neutral mood state.
Depression - A state of upset or "blue" moods including symptoms such as: feelings of sadness and hopelessness, decreased motivation, negative thoughts, increased need for sleep, introversion, reduced activity, motivation and concentration.
Hypomania - A state of elevated mood in which a patient exhibits symptoms such as: increased energy and activity levels, decreased need for sleep, racing thoughts, extreme extroversion, unusual cheerfulness and over confidence.
Major Depression - Otherwise known as Unipolar Depression, Major Depression is a state where the patient experiences all of the symptoms of depression to a more severe degree. In addition, during Major Depression, patients experience suicidal ideation and thoughts of death.
Mania - Mania, or full blown mania, is a state in which a patient experiences all of the symptoms of hypomania to a more extreme degree. Patients in a manic state may make extremely rash and destructive decisions with no thought of the consequences.
 |
Backgrounds of Cyclothymic Individuals
Will Johnson's Story
Will stumbled off of the curb and into the street. The smoke from his marijuana joint billowed in front of him, clouding his view of the fluorescent-lit San Francisco night. He glanced at the homeless people lining the sidewalk. The other homeless people, he reminded himself. Will kept forgetting that he was the newest member of this unfortunate group. He wondered if he was the only person sleeping on the dirty benches who carried around two college degrees in his fraying backpack. He clumsily made his way towards "his" spot, a rusted bench under the broken street light. He found that most of the other homeless people on the block preferred the comfort of the shallow lights, but Will preferred the dark. It gave him some sense of security that none of his college friends would step out of one of the local bars and notice their old buddy sleeping on the corner with his college football jacket under his head.
He arrived at his bench and found it already occupied. He took a few steps closer, but the dark angry eyes of the heavyset man who had already settled in for the night drove him back, cursing under his breath. He still could not believe that this situation was actually his life. Four years ago he had made a small fortune in the dot-com industry, and lived in a spacious apartment in the most popular neighborhood of the city. Unfortunately he had chosen at the time to use his newfound wealth to take extravagant vacations and to pay his exorbitant rent payments. Shortly afterwards his stock began to fall and his abandoned college payments caught up with him. Will decided to go to work, but after a few weeks in a job he would get bored and irritable and quit. Once, after working for only four weeks as an assistant in a research facility he announced to his superior he was not coming back to work the next day. His boss informed him that he was bound by contract to stick around for another three weeks until they found a replacement, but Will ignored the warning. Before he knew it he had lost a lawsuit, his apartment and all of his savings.
At first Will appealed to his parents for help. They were disgusted at the manner in which he had "wasted his potential," but nevertheless agreed to send him money. Will used all of the money to buy marijuana. He could not help it, it was the only way he could stabilize himself. He preferred to be high and on the streets than to be sober and trying to hold down a job. He could not stand the ups and downs of his mood, his emotions abruptly yanking his life in and out of order. And now this was his life, trying to stabilize his mood with huge quantities of marijuana when he barely had money for food, sleeping on the street and pondering his failures.
The next morning Will woke up unsure if he had slept at all. He stood up shakily and sauntered towards the small kiosk that was already setting up shop on the corner. He glanced at the newspaper, it was Thursday, the day his parents wired him money. He whistled while he brushed his teeth, ignoring the strange looks from the various people in business suits who hurried towards long days in anonymous workplaces. By the time he walked into the Western Union office, he had washed his face and shaved in the public bathroom and he was beginning to feel like a normal human being. He could tell it was going to be a good day and he knew that he had to take advantage of it before the inevitable downturn towards depression as soon as the sun set and he remembered that he had nowhere to sleep. Suddenly his mood took a premature nosedive. His father was standing in the lobby of the building, arms crossed. Will saw his own bloodshot eyes and dirt-caked nails reflected in his father's look of disgust.
"I knew it," his father said stonily.
"What are you doing here? I am thirty-four years old and you have no reason to be interfering with my life," Will said in anger, slurring his words and hoping his father would not notice the undertone of relief in his voice.
"You are coming with me, now. I am taking to the hospital. You need help."
Karen Newport's Story
Karen was all smiles as she signed the rent agreement. The decision was freeing and empowering, and she could not wait to get home to tell her husband of twenty years that she was no longer prepared to put up with his nonsense. What did I do this time? She could already hear him saying in that irritating voice he used when he wanted her to know that he was just trying to placate her. Maybe this time she would not talk to him at all, she would just take her daughter, pack her bags and leave a note on the refrigerator door. Karen pulled into her driveway and took a deep breath. She pulled the bottle of whisky out from the glove compartment and contemplated it for a few moments. She was having a good day today; maybe she did not need the alcohol. Then again, her mood was likely to fall apart any moment. She was, after all, about to move out of her home of two decades. She unscrewed the top, and slowly swallowed a bit of her potent medicine. She closed the bottle and got out of the car.
She found her sixteen year-old daughter huddled over her calculus homework in her bedroom. For a moment Karen felt overwhelmed with doubt, not wanting to shatter her daughter's simple life over this insanity. But it was too late now, the decision had been made and the contract signed.
"Annie, honey…" Karen started, and then stopped, taken aback by the sharp look on her daughter's face.
"What is it mom. I know that you've gone and done something again. I heard you arguing with dad this morning. What were you fighting about anyway?" Annie asked accusingly. The truth was, Karen did not remember how the fight had started, she only knew that she had woken up angry and everything had gone downhill from there.
"Mom, whatever it is, it is a bad idea," Annie continued, "Remember what happened last time." She turned her back to Karen and returned to her homework.
Karen remembered what had happened last time. Last time she had fought with her husband she had decided that she needed a break, and had taken a significant chunk out their daughter's college fund to purchase a ticket on an extravagant one month cruise in the Mediterranean. She had flown to New York to meet the group, but never boarded the ship. It had suddenly seemed like a petty solution to a problem that was not so big after all. She had returned home in tears, apologizing to her husband and daughter for her brief disappearance. They had forgiven her. They were good people, she was lucky. She doubted that most other men would have stuck around through such tumultuous mood swings.
Suddenly Karen realized that moving out was a terrible idea. She loved her husband and had no intention of leaving him. But what was she going to do with the contract she had already signed? She sat down on a stool in the kitchen and began crying. Why was she like this? Why, at 55, had she not yet learned to hold down a job? Why couldn't she get through a day without secretly guzzling down alcohol? Why couldn't she be a steady trustworthy wife and mother? Karen decided that it was time to get some help.
|
What is Cyclothymic Disorder?
Both Will and Karen were eventually diagnosed with Cyclothymic Disorder. Both individuals saw several mental health professionals (including college counselors, alcohol and drug counselors, social workers, psychologists and psychiatrists) over the course of many years prior to their final diagnoses.
Mental health professionals who make formal diagnoses of their patients' mental illnesses usually use standardized lists of observable symptoms to classify an illness. Will and Karen were diagnosed with Cyclothymia based on the list provided by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criterion. The DSM-IV guidelines define Cyclothymic Disorder as: "a chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms..and numerous periods of depressive symptoms... The hypomanic symptoms are of insufficient number, severity, pervasiveness, or duration to meet full criteria for a Manic Episode, and the depressive symptoms are of insufficient number, severity, pervasiveness, or duration to meet full criteria for a Major Depressive Episode."
The DSM-IV list of symptoms to classify a patient as Cyclothymic is as follows:
- For a minimum of two years the patient has had multiple periods of hypomanic symptoms as well as many periods of depression that do not meet the criteria for Major Depressive Disorder.
- The patient has not been free of mood swings for more than two months of the two year period.
- During the first two years the patient experienced symptoms of this disorder, he/she did not fulfill criteria for Manic, Mixed or Major Depressive episodes.
- Schizoaffective disorder does not provide a better explanation for the patient's symptoms, and the patient's symptoms are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Psychotic Disorder Not Otherwise Specified.
- The patient's symptoms are not cause by a general medical condition of by the use of substances, including prescription medications.
- The patient's symptoms cause clinically important distress or inhibit the patient's ability to function in work, social and personal environments.
Unfortunately, due to the finite nature of these classifications and the ambiguous nature of many mental illnesses, these guidelines often fall short of precision. For example, Will did experience a true manic state, in which he disregarded commitments and recklessly spent all of his savings without thought for the consequences. Will also maintains that his mood switches from hypomanic to depressive in hours, rather than days or weeks, which does not fit the DSM-IV definition. In addition, Karen experienced mixed states, or states in which she felt both hypomanic and depressive symptoms simultaneously. In the example in CEU 1 Karen was hypomanic, recklessly signing a contract on a new home. At the same time she felt depressed and agitated, after her argument with her husband.
In spite of these apparent contradictions, after finally being diagnosed with Cyclothymic Disorder and receiving treatment, both Will and Karen experienced reductions in their symptoms and managed to improve their quality of life. Had either of these individuals been diagnosed during their earlier experiences with healthcare professionals, the severity of their symptoms and harshness of their consequences may have been avoided.
When Karen first saw a psychologist nearly ten years ago, she was in a depressive period. The counselor failed to ask questions about manic or hypomanic symptoms and mistakenly treated Karen for depression, which thrust her into a more extreme hypomanic state combined with mixed periods.
Cyclothymia is particularly difficult to diagnose, because depressive and hypomanic symptoms can be uniquely ambiguous. When Karen originally saw a psychologist, the possibility of Bipolar Disorder was addressed. However, once Karen understood the symptoms of manias and major depressions, she knew that she was not part of that group. Karen knew that she never experienced the psychosis and extreme recklessness often associated with manias, and she never felt the suicidal ideation associated with major depressions. The possibility of hypomanias and mild depressions were never discussed.
After failing to address their problems with mental health professionals, both Will and Karen resorted to substance abuse to self-medicate and to soothe their mood swings.
As healthcare professionals, it is important to be aware that many other psychiatric, medical and drug-induced disorders may closely resemble Cyclothymic Disorders. Important illnesses to examine and explore in the event that you are faced with an individual with the above symptoms include: Bipolar I or II Disorder with Rapid Cycling, Borderline Personality Disorder, Cushing's Disease, Acquired Immune Deficiency Syndrome (AIDS), Epilepsy, Huntington's Disease, Hyperthyroidism, Migraines, Multiple Sclerosis, Trauma, Withdrawal from Antidepressants and many, many others. Overall it is extremely important to examine every possible facet of an individual's health and history before assuming that he or she may have Cyclothymic Disorder.
Another important factor to explore in the identification of Cyclothymia is the family history of the individual. About 30% of all patients with Cyclothymia have family histories of Bipolar I Disorder. An examination of the family histories of Bipolar I Disorder patients shows a tendency toward these conditions that alternates across generations, i.e., Bipolar I Disorder in one generation, followed by Cyclothymia in the next generation, followed by Bipolar I Disorder again in the third generation. The incidence of Cyclothymia in families with Bipolar I Disorder is much higher than in families with other mental disorders or in the general population. When asked, many patients will describe a family history of Major Depression, Bipolar Disorder or alcohol/drug dependence. Will has an extensive family history of mental illness, including his grandmother, who was Cyclothymic and alcoholic, and his mother, whose severe depression and hallucinating eventually culminated in her institutionalization in a catatonic state. Karen suspects that her mother suffered from undiagnosed depression, her daughter was treated for depression and her older sister is currently being treated for major depression. In addition, Karen has one nephew who is struggling with depression and another who has Bipolar I Disorder.
Because Bipolar Disorder and Cyclothymic Disorder are similar, it is important for healthcare professionals to differentiate between the two. Bipolar individuals are significantly easier to diagnose than Cyclothymic individuals, because they may describe their depressive state as suicidal and nonfunctioning, and their manic state can reach levels of psychosis, when they lose touch with reality. Most individuals with Cyclothymic Disorder experience subtler up/down cycles, but these cycles are debilitating. Cyclothymic cycles may be seen through changes in sleep schedule, work efficiency, level of talkativeness and concentration. Cyclothymic individuals also often have difficulty maintaining long-term relationships, and often describe many short-term relationships and multiple marriages. Repeated changes in work and living environments are also common.
