Day-to-Day Life: Cyclothymia Before Treatment
In this section I will explore the pretreatment experiences of Will and Karen, and we will see how the symptoms of Cyclothymia manifest themselves in individuals' lives.
Will
Will is a thirty-five year old male from San Francisco with two advanced educational degrees. Will's severe Cyclothymia symptoms began ten years ago while in university, although he believes that he has been experiencing fluctuations in mood from as early as grade school. While in college, Will began having hypomanic periods during which he would experience sleeplessness and racing thoughts. During these states Will would often overcommit himself to various courses, projects and activities. Occasionally his hypomania would bring feelings of elation, but often his hypomania would present itself as dysphoric, with irritable, agitated feelings accompanied by excess energy. Will's depressive states involved severely reduced motivation and obsessive thought processes. Due to the instability of his moods, Will changed his major five times. Finally it was the obsessive thinking, which was mainly directed towards ex-girlfriends, which drove Will to first seek professional help.
He saw a counselor and a psychologist, both of whom dismissed his complaints as oversensitivity and informed him that he had an "artistic personality." Disheartened, Will turned to drugs and alcohol to soothe the extremity of his moods.
Will's insomnia worsened to the point that he would go months without sleeping for more than three and a half hours consecutively. While hypomanic, Will would often begin intense relationships with women, feeling deeply "in love" and entertaining grandiose thoughts about his future with the woman. However, each relationship inevitably failed whenever his mood turned downwards and Will began to feel doubtful and indifferent towards his partner. His sudden fluctuations in personality drove away personal and romantic relationships.
After finishing school Will's hypomanias expanded to include reckless money-spending, while his depressions prevented him from maintaining a steady job. During this period of Will's life, some of his hypomanias accompanied symptoms of full-blown manias, further disrupting his life. Will's severe symptoms led to periods of homelessness and even near-starvation. Five years later his drug abuse and continued obsessive thinking and sleeplessness drove him to attempt to seek help once again.
Prior to treatment, Will was unable to maintain stability in any facet of his life. Will found it difficult to cope in any work environment. His enthusiasm and motivation arbitrarily came and went, resulting in continuous changes of work place. In spite of his multiple degrees in anthropology and interdisciplinary arts, Will has never held a job for more than two years and has never gained a position beyond entry level.
Karen
Karen is a 55 year old woman who has been experiencing symptoms of a mood disorder since her early teenage years (12-13). At the age of 18 Karen began to experience noticeable fluctuations in her motivation and enthusiasm for new projects. Her abrupt changes in personality from elated, cheerful and confident to sad, gloomy and doubtful led to serious and damaging disruptions of her lifestyle. Karen noticed that all of her life events began to come in multiples. She studied towards multiple degrees and held numerous jobs in a plethora of fields. She started various unsuccessful businesses in home decorating, pet sitting, word processing, wallpaper consulting/hanging, peony farming and candle making. Each of these ventures failed as soon as her mood turned towards depression, and each failure resulted in tremendous financial loss. In addition, Karen moved about fifteen times prior to getting married, which forced her into residential stability.
Karen has a reduced need for sleep during her hypomanias and extreme hypo-somnia during her depressions.
Karen did not seek help for many years because she did not realize that the symptoms she was experiencing were a disorder that could be treated. Karen has a nephew with Bipolar Disorder and is therefore familiar with the symptoms of that illness. When Karen saw that her symptoms did not meet the criteria for a full blown mania or major depression she thought there was no available treatment for her problem.
Finally, while accompanying her daughter to counseling ten years ago, her daughter's psychologist suggested that Karen might be depressed and angry. Karen began seeing a counselor herself and was diagnosed with and treated for depression (non-suicidal). Treatment with antidepressants thrust Karen into a severe and continuous hypomanic/mixed state. She often felt anxious and over energized, with severe insomnia. She made reckless decisions with money management and experienced racing thoughts and feelings of lack of control. She would take her daughter on elaborate excursions without informing her husband or her daughter's school and go out to bars and clubs on a regular basis.
When Karen stopped using the antidepressant medications her depressive periods returned, leading to irritability and oversleeping. The fluctuations caused serious problems in Karen's marriage, as she would grow close to her husband during her hypomanias and push him away during her depressions.
In a desperate attempt to smooth out the edges of the hypomanias and depressions Karen began to abuse alcohol. Two years ago Karen began seeing a drug abuse counselor who diagnosed her with Cyclothymic Disorder.
What Will and Karen Have in Common
Both Will and Karen are currently being treated through both medications and talk therapy. Both individuals experienced some of the most common and most intrusive symptoms of Cyclothymic Disorder, including fluctuations in motivation and need for sleep, instability in work and residential environments and difficulty maintaining relationships because of changing personality. Both suffered unnecessarily because of lack of or failed diagnosis and treatment of their illnesses in early stages. Overlooked issues and misdiagnoses are common with Cyclothymic patients, and this course is designed to help you prevent this unfortunate problem from continuing. In the following CEU you will find methods of identifying and helping Cyclothymic individuals so that their illness might be treated as soon and as effectively as possible.
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What You Can Do:
How to Identify and Help an Individual with Cyclothymic Disorder
The following section is designed to help you approach and assist and individual whom you suspect may have Cyclothymic Disorder. This CEU contains guidance from mental health professionals who have experience with Cyclothymia, and advice from patients with Cyclothymia. Please keep in mind that these are suggestions, not requirements, and you should develop your own procedure for how to deal with this situation.
The onset of Cyclothymia can be fairly insidious and difficult to identify, but usually occurs in mid-adolescence with a mean age at onset of 14 years. Because certain symptoms of Cyclothymic Disorder such as hyperactivity and distractibility are also characteristic of Attention-Deficit/Hyperactivity Disorder (ADHD), the two can easily be confused. The main difference is that in the individual with Cyclothymic Disorder the symptoms of hyperactivity and distractibility are episodic, with rapid swings in activity and attention levels.
Medical professionals advise first and foremost to recommend psychological and/or psychiatric treatment to any patient that you suspect may have Cyclothymic Disorder or a similar illness. That may sound simple, but because many people who have Cyclothymia enjoy their hypomanias, or consider their hypomanic state to be "normal," these individuals are often resistant to suggestions of treatment. If you suspect Cyclothymia in an individual who is not willing to attempt treatment you should try to explain the disorder and the reasons why you suspect that they might have it. Explaining the difference between hypomania and mania may be particularly important, as many people, especially those who have been treated previously for other mental illnesses, are familiar with the symptoms of a full blown mania and are aware that this is not what they are experiencing. A clear explanation of a hypomanic stage (elevated mood, reckless behavior, reduced need for sleep) may allow these patients to identify these symptoms within their own experiences.
It is crucial that you explain to any individual with suspected Cyclothymic Disorder that talk-therapy and medications do have a high degree of success with such cases. It will be reassuring for these individuals to understand that with treatment Cyclothymic patients usually experience a reduction in their depressive states, increased control over their moods, improved work capabilities and improved quality of relationships. Both Will and Karen have experienced significant reduction in their symptoms and stabilization of their lifestyles through talk-therapy, medication and other treatments that will be discussed later on. Medications commonly prescribed for Cyclothymia (and recommended by the DSM-IV guidelines) include: Antimanic Drugs, Lithium Carbonate, Carbamazepine (Tegretol), Valproic Acid (Depakene, Depakote) and Verapamil (Calan). The following chart provides a brief overview of these medications and their effects:
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* The side effects listed above do not encompass all of the possible side effects associated with these medications.
As you can see from the preceding chart, medical research for mood disorder treatment is a work in progress. Researchers are still unsure what treatments are the most effective for which individuals and patients with mood disorders often spend lengthy periods of time adjusting their drug types and dosages. It is still unclear how many of the available treatments actually work within the body.
While the prospect that treatment is available often improves a patient's state of mind, it is also important that you express clearly that there is no "magic pill" for Cyclothymia. Every patient that you refer for psychiatric treatment and talk-therapy should be aware that both treatments take time. While recent research is improving these medications, today most biomedical treatments for psychiatric illnesses take about one month to take effect, and then there is usually a period of several months in which patient and doctor work together to adjust the dose to fit the individual's needs.
As a medical professional it is vital for you to understand the seriousness of this illness. Among Cyclothymic patients followed from 1 to 3 years, 35-40% have progressed to Bipolar I or II Disorder, a development which can lead to complete destruction of personal and professional lives, and even suicide. Many psychiatrists believe that with early treatment, Cyclothymic patients have a better chance of delaying or even preventing this deterioration.
As you read above, most patients with Cyclothymia differ in significant ways from the DSM-IV criterion for the illness, so if you suspect Cyclothymia, yet the patient does not seem to match the symptom set precisely, you should not necessarily rule out the illness.possibility. One of the most important thingsfacts to identify is the cycle from depression to hypomania. If you encounter an individual in a depressed stage, you should always inquire as to hypomanic periods or moods, naming specific characteristics and symptoms, and vice versa. Keep in mind that Cyclothymic individuals, unlike those with Bipolar Disorder, do have periods when their mood is categorized as normal, so if an individual's present behavior is not obviously hypomanic or depressed, yet he/she is complaining of Cyclothymic symptoms, you should not rule them out.
If you suspect Cyclothymia, you should investigate the possibility of comorbidity with substance abuse. Cyclothymia is a common diagnosis in those with substance abuse, and substance abuse is common in those diagnosed with Cyclothymic Disorder. This leads us to ask which condition pre-exists. Research indicates that in most cases of this sort, drugs (particularly alcohol and marijuana, but sometimes harder drugs such as cocaine) are used as self-treatment. If the individual denies substance abuse, you might warn them that there is a large danger of Cyclothymic individuals attempting to self-medicate through drugs and alcohol to calm their extreme moods.
Will and Karen both resorted to substance abuse after failing in their initial attempts to seek treatment, but now that their diagnoses have been finalized they have both found effective and safe treatment methods.
Will has found that the most helpful part of his treatment is a mood diary. As a healthcare professional, you may suggest this diary as an activity for Cyclothymic individuals. Will recommends a mood charting method described in Dr. David Burns book of cognitive psychology called Feeling Good: The New Mood Therapy which contains a process of writing down and analyzing irrational thoughts in five steps:
1. Write down the incident or situation in which you felt emotional distress.
2. Write down the specific feeling that you experienced at that time.
3. Try to understand that underlying thought process or self-deprecating idea that led to that thought (e.g.I am stupid/I am ugly).
4. Dispute the thought with facts and logic, with the assistance of Dr. Burn's list of cognitive "mistakes" such as "mind reading" (assuming people are talking about you or looking down on you) "all or nothing thinking," etc.
5. Write down the new feeling or conclusion that you come to after this explanation.
Will, as well as many other Cyclothymia patients, say that this mood diary has helped them to understand and control their mood swings, separating his irrational thoughts from his rational ones.
Both Will and Karen, like many other Cyclothymic individuals, have discovered that maintaining stability in many aspects of their lives have helped control their moods. This includes a regular sleeping schedule and a regular and healthy diet. Will nearly always experiences a depressive period if he has a serious disruption in his sleep schedule.
Another treatment method that you might suggest to Cyclothymic individuals is participation in a regular activity, such as kickboxing or meditation. Will noticed a significant improvement when he began taking regular yoga classes and Karen has felt better since she has begun weekly art therapy. This treatment method is non-intrusive and enjoyable, and is a good activity to suggest to individuals who are enduring the difficult period at the beginning of treatment waiting for the medications to take effect.
Including Will and Karen, every individual interviewed for this course expressed a strong desire to have been given information about Cyclothymia upon their diagnosis. Information about this illness is not readily available and is often vague. If possible, you should have some handout material about Cyclothymic Disorder that you can distribute to individuals whom you suspect might suffer from this disorder. A sample, one-page handout about Cyclothymic Disorder is included at the end of this course. It is recommended that you keep a copy of this handout should you encounter a patient who is seeking more information about this illness.
* Activity - Keep a mood journal for yourself for three or four days. Make sure to try and write in it when you are in a negative mood (angry, upset, irritated) and to detail why you feel that way. Did it help improve your mood? Why?
