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Depression

Cyclothymic disorder (also known as cyclothymia) is characterized by a person experiencing numerous periods of hypomanic symptoms and periods with depressive symptoms. Neither periods of hypomania nor depression meet the criteria for a diagnosis of hypomania, bipolar II disorder, or a major depressive episode

Cyclothymic disorder is typically a chronic disorder that can be challenging to treat. In order to qualify for a diagnosis of this disorder, a person must experience periods of mood disturbance for at least 2 years (1 year in children and adolescents), and has never been without the symptoms for more than 2 months at a time. Cyclothymic disorder usually begins in adolescence or early adult life and is sometimes considered to reflect a temperamental predisposition to other bipolar and related disorders.

A person experiencing this disorder will not have experienced a major depressive episode, a manic episode, nor a mixed episode during the first 2 years of the disturbance.

Specific Symptoms of Cyclothymic Disorder

  • Numerous periods of hypomanic symptoms and of depressive symptoms that do not meet the criteria for either disorder, for at least a period of 2 years (1 in teens and children).
  • The periods of hypomanic and depressive symptoms are present more at least half the time, and the individual has not been without the symptoms for more than 2 months at a time.
  • Criteria for a major depressive episode, manic episode, or hypomanic episode have never been met.
  • The symptoms are not better explained by schizoaffective disorder, schizophrenia, or a related delusional disorder.

According to the American Psychiatric Association (2013), after the initial 2 year period (1 year in children and adolescents) of cyclothymic disorder, there may be superimposed manic or mixed episodes. In this case, bipolar I disorder or bipolar II disorder should be diagnosed and the cyclothymic disorder diagnosis should be dropped. If the person experiences a major depressive episode after the 2 year period, a diagnosis of major depression disorder should be made instead.

Many people with this diagnosis also experience high levels of anxiety. Therefore a clinician may add the clinical specifier, “with anxious distress” when making a diagnosis of cyclothymic disorder.

In order for this disorder to be diagnosed, the disturbance should not be better accounted for by schizoaffective disorder and cannot be superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified. The symptoms can not be due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism). Furthermore, the symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The lifetime prevalence of cyclothymic disorder is approximately 0.4 to 1 percent in the United States. In the general population, cyclothymic disorder is apparently equally common in males and females. In clinical settings, females with cyclothymic disorder may be more likely to present for treatment than males.

For more on treatment, please see general treatment guidelines for cyclothymic disorder.

 

This entry has been updated in accordance with DSM-5 changes; diagnostic code 301.13.

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, Fifth edition. Arlington, VA.

Caponigro, J.M. & Lee, E.H. (2012). Bipolar Disorder: A Guide for the Newly Diagnosed. New Harbinger.

Fountoulakis, K.N. (2015). Bipolar Disorder: An Evidence-Based Guide to Manic Depression. Springer: New York.

Cyclothymic Disorder (Cyclothymia) Symptoms

Depression

Table of Contents


Psychotherapy

There is no clear treatment of choice for cyclothymic disorder. Either psychotherapy or medication can be tried first, or in conjunction with one another.

Treatment often takes the form of individual psychotherapy, although group treatment can also be helpful for this disorder. The specific content and techniques used to help treat the person who suffers from this disorder will vary widely. Some clinicians have found a psychoeducational approach of the disorder to be especially helpful. Since cyclothymic disorder tends to be more of a chronic condition, helping the client learn to be able to predict their mood swings and increase their level of coping skills becomes vital. Additional focus on the individual’s interpersonal relationships with others may be beneficial. Self-esteem and issues of self-worth and value often come up in therapy and might be helpful to discuss.


Medications

A trial of lithium carbonate is often tried, especially if the mood swings seem to be similar to those found in bipolar disorder. Prescription of such a medication, though, should be dependent upon a thorough clinical examination and history of the patient. Lithium can help reduce manic symptoms and the overall frequency of the cycling, but may also be ineffective in the large minority of people who take it.


Self-Help

Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them.  Many support groups exist within communities throughout the world, which are devoted to helping individuals with this disorder share their commons experiences and feelings.

Patients can be encouraged to try out new coping skills and affect regulation with people they meet within support groups. They can be an important part of expanding the individual’s skill set and develop new, healthier social relationships.

For more on symptoms, please see cyclothymic disorder symptoms.

Cyclothymic Disorder Treatment

Depression

Bereavement is a normal reaction to loss in human beings in virtually every culture across the world. There are no set rules for how long “normal” bereavement lasts, as each person and each loss is very different. Therefore, bereavement tends not to be diagnosed unless it has gone on for a very significant period of time and significantly impacts the person’s life. Getting over or past the lost of a loved one can be challenging for nearly everyone.

But for some, the loss of a loved one is too much, causing them to enter into a clinical depression that may need further attention or treatment.

Bereavement is diagnosed when the focus of clinical attention is a reaction to the death or loss of a loved one. As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a major depressive episode (e.g., feelings of sadness and associated symptoms such as insomnia, poor appetite, and weight loss).

The bereaved individual typically regards the depressed mood as “normal,” although the person may seek professional help for relief of associated symptoms such as insomnia or anorexia. The duration and expression of “normal” bereavement vary considerably among different cultural groups.

The diagnosis of major depressive disorder is generally not given unless the symptoms are still present 2 months after the loss.

However, the presence of certain symptoms that are not characteristic of a “normal” grief reaction may be helpful in differentiating bereavement from a major depressive episode.

These include:

  1. Guilt about things other than actions taken or not taken by the survivor at the time of the death;
  2. Thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person;
  3. Morbid preoccupation with worthlessness;
  4. Significant psychomotor retardation (e.g., it’s hard to get moving, and what movements there are are slow);
  5. Prolonged and serious functional impairment; and
  6. Hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person.

Bereavement Symptoms

Depression

“Specifiers” are professionals terms that a mental health professional may use to add more detail to a person’s bipolar disorder or depression diagnosis. The specifiers below come from the diagnostic reference manual mental health professionals use to diagnose mental disorders (the DSM-5).

“With mixed features” is a specifier that can be added to either major depressive disorder or bipolar I or II disorder, and it applies when a person experiences both symptoms of depressed mood and mania (though one or the other would be considered predominant) within the same episode.

As described in detail below, the mixed features specifier would be applied following the current or most recent state the person is/has been in: manic, hypomanic, or depressed.

Manic or hypomanic episode, with mixed features

This specifier applies when full criteria are met for a current or most recent manic episode or hypomanic episode, and at least three symptoms of depression are also present during the majority of days within this episode. These depressive symptoms (listed below) must be distinct from the person’s usual behavior and able to be observed by others who are close to or in regular contact with the person (e.g., a partner, family member, coworker, or friend).

  1. Experiencing significantly depressed mood where the person feels sad or empty or the observation is made by others (e.g., “he appears tearful”).
  2. Losing interest or pleasure in all, or almost all, activities the person would usually enjoy doing (e.g., hobbies, exercise), as indicated by either the person’s account or observations made by others.
  3. Speaking or talking more slowly than is normal for the person nearly every day (this “psychomotor retardation” can be observable by others).
  4. Fatigue or loss of energy.
  5. Feelings of worthlessness or excessive or inappropriate guilt (e.g., focusing on things the person feels they could have or should have done in the past).
  6. Recurrent thoughts of death (not just fear of dying) or suicidal ideation/actions. Intensity of suicidal thoughts/behaviors range from fleeting morbid thoughts to making an actual suicide attempt. Also included along this spectrum are suicidal thoughts without a specific plan, and thoughts that include forming a specific plan for committing suicide with or without actual intent to carry it out.
  • For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features, due to the marked impairment and clinical severity of full mania.
  • The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication, other treatment).

Depressive episode, with mixed features

This specifier applies when full criteria are met for a current or most recent major depressive episode. Thus, a person can have major depressive disorder (MDD) with mixed features and not necessarily meet for a bipolar spectrum disorder (i.e., the person does not fully meet for mania or hypomania to qualify for a bipolar diagnosis). However, mixed features in MDD are usually a “red flag” and an indicator the person will go on to develop bipolar I or II disorder. As a result, it is clinically useful to note the presence of this specifier for treatment planning and monitoring of response to treatment.

In a depressive episode with mixed features, full criteria are met for a major depressive episode, and at least three of the following manic/hypomanic symptoms are present during the majority of days during the current or most recent episode of depression:

  1. Experiencing an excessively elevated, expansive mood (e.g., feeling high, excited, or hyper).
  2. Inflated self-esteem or grandiosity (e.g., feeling like you are especially important in some way akin to a deity or an authority figure).
  3. More talkative than usual or feeling pressured to keep talking.
  4. Flight of ideas or subjective experience that thoughts are racing.
  5. Increase in energy or goal-directed activity (either socially, at work or school, or sexually).
  6. Increased or excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
  7. Decreased need for sleep (feeling rested despite sleeping less than usual — not simply inability to sleep, as in insomnia).
  • For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features.
  • The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication, or other treatment).

 

Prior to the 2013 DSM-5, this mood disorder specifier was referred to as an ‘episode’. Other specifiers have also been added to bipolar disorder and major depressive disorder

Mixed Features Specifier of Bipolar Disorder & Depression

Depression

Bipolar Disorder With Mixed Features

Click on the link above to learn more about bipolar disorder with mixed features.

Bipolar Disorder or Depression with Anxious Distress

This specific manifestation of bipolar disorder is applied when a person has noticeable symptoms of nervousness/anxiety during a related mood episode. A person must have at least 2 of the following symptoms the majority of days during the current or most recent mood episode (Mood episodes include mania, hypomania, or depression.):

  1. Feeling irritable, short-fused, or “keyed up”
  2. Feeling unusually restless.
  3. Difficulty concentrating because of worry.
  4. Feeling of dread that something awful may happen.
  5. Feeling that the individual might lose control of himself or herself.

Bipolar Disorder or Depression with Melancholic Features

The specifier “with melancholic features” is applied when an individual is at the depths of a depressive episode. In this state, there is almost no access of capacity for feelings of pleasure. A helpful guideline for determining whether you are in a melancholic state is the inability to react emotionally in a way that is expected given the event. Either mood does not brighten at all, or it brightens only slightly. For example, one may only feel only fleeting positive reactions 20 to 40 percent of the time to a positive event.

During melancholic depression, individuals exhibit a slower rate and energy level for responding to events (compared to their norm).

Melancholic features are more frequent in inpatients, as opposed to outpatients. These features are also less prevalent in mood episodes of persons who are not diagnosed with a severe mood or psychotic disorder.

Bipolar Disorder or Depression with Atypical Features

This specifier refers to the case when the clinical presentation of a mood episode does not fit the significant majority of those with the same episode. However, these atypical symptoms are prevalent enough in those with mood disorders to be noteworthy. For instance, though chronic low mood is typical major depression, in atypical cases, a person can be “cheered up” to the degree that they no longer feel depressed for a period of time in response to a positive event (for example, an adult receives a visit from children; a person receives compliments or an award).

To be diagnosed with this subtype of depression, 2 symptoms involving changes in sleeping, eating, motor movements, or interpersonal communication must be evident, including:

  1. Significant weight gain or increased appetite.
  2. Hypersomnia (sleeping more/for longer periods than usual).
  3. Feeling heavy or leaden in arms/legs as if one is “weighed down.”
  4. Having constant fear of rejection (this can be consistent with when a person is not depressed, but is exacerbated during a period of depression); this interpersonal sensitivity must interfere at the workplace or in personal life.

Bipolar Disorder or Depression with Psychotic Features

This specifier applies if delusions or hallucinations (auditory or visual) are present at any point during a mood episode. See psychotic disorder for a description of such symptoms.

Bipolar Disorder or Depression with Peripartum Onset

Most commonly referred to as postpartum depression, you can learn more about this disorder and specifier here.

Bipolar Disorder or Depression with Seasonal Pattern

Most commonly referred to as seasonal affective disorder, you can learn more about this disorder and specifier here.

This specifier can be applied to the pattern of major depressive episodes in bipolar I disorder, bipolar II disorder, or major depressive disorder, recurrent. The essential feature is that periods of depression tend to occur and remit during certain times of the year. In most cases, the episodes begin in fall or winter and remit in spring. Less commonly, there may be recurrent summer depressive episodes.

This pattern of onset and remission of episodes must have occurred during at least a 2-year period, without any nonseasonal episodes occurring during this period. In addition, the seasonal depressed periods must substantially outnumber any nonseasonal depressive episodes over the individual’s lifetime. Younger persons are more at-risk for seasonal depression. This specifier does not apply to those situations in which the pattern is better explained by seasonally linked psychosocial stressors (e.g., seasonal unemployment or school schedule).

Additional Specifiers of Bipolar Disorder & Depression

Persistent Depressive Disorder (Dysthymia) Symptoms

Depression

Persistent depressive disorder, formerly known as dysthymic disorder (also known as dysthymia or chronic depression), was renamed in the updated DSM-5 (American Psychiatric Association, 2013). Dysthymia is also known as chronic depression, because the primary feature of persistent depressive disorder is a depressed mood that doesn’t go away over a long period of time.

The essential feature of persistent depressive disorder (dysthymia) is a depressed mood that occurs for most of the day, for more days than not, for at least 2 years (at least 1 year for children and adolescents).

Symptoms of Chronic Depression

This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder. Major depression may precede persistent depressive disorder, and major depressive episodes may occur during persistent depressive disorder. Individuals whose symptoms meet major depressive disorder criteria for 2 years should be given a diagnosis of persistent depressive disorder as well as major depressive disorder.

Individuals with persistent depressive disorder describe their mood as sad or “down in the dumps.” During periods of depressed mood, at least two of the following six symptoms from are present:

  • Poor appetite or overeating
  • Insomnia or hypersomnia
  • Low energy or fatigue
  • Low self-esteem
  • Poor concentration or difficulty making decisions
  • Feelings of hopelessness

Because these symptoms have become a part of the individual’s day-to-day experience, particularly in the case of early onset (e.g., “I’ve always been this way”), they may not be reported unless the individual is directly prompted. During the 2-year period (1 year for children or adolescents), any symptom-free intervals last no longer than two months.

In children and adolescents, their mood may also be marked by increased irritability for a year or longer.

Furthermore, in order to be diagnosed with persistent depressive disorder, there has never been a manic episode, a mixed episode, or a hypomanic episode in the first 2 years, and criteria have never been met for cyclothymic disorder.

In order to meet the diagnostic criteria for dysthymic disorder, the symptoms may not be due to the direct physiological effects of the use or abuse of a substance (for instance, alcohol, drugs, or medications) or a general medical condition (e.g., cancer or a stroke). The symptoms must also cause significant distress or impairment in social, occupational, educational or other important areas of functioning.

For more information about treatment, please see general treatment for dysthymic disorder.

 

This criteria has been adapted for DSM-5. Diagnostic code: 300.4.

Persistent Depressive Disorder (Dysthymia) Symptoms

Persistent Depressive Disorder (Dysthymia) Symptoms

Depression

There are a number of effective treatment approaches to help treat dysthymic disorder (also known as dysthymia). Often times a person with dysthymia will seek out treatment because of increased stress or personal difficulties which may be situationally-related. Only after a careful diagnostic interview is conducted (or after a few therapy sessions) may the chronic nature of the problem become apparent.

The best treatment approach for people with dysthymia appears to be a combination approach — psychotherapy combined with antidepressant medication. One large multisite study in the New England Journal of Medicine by Keller and colleagues (2000), for instance, had patients randomly assigned to one of three treatments: a depression-focused cognitive-behavioral therapy (CBT) program, the antidepressant Serzone (nefazodone), or to a combination of the two. About three-quarters responded to the combination, compared with about 48 percent for each individual condition.

“The combination of the two was whoppingly more effective than either one alone,” noted the researchers. “People suffering from chronic depression often have longstanding interpersonal difficulties, and the virtue of combined treatment in this case may be that it simultaneously targets both depressive symptoms and social functioning.”

Psychotherapy

There are many different types of psychotherapy available to help someone with dysthymia.

Before psychotherapy beings, a mental health professional will conduct a thorough evaluation to evaluate the individual’s current state of functioning, to assess mood type and severity, check for suicidal ideation and plan, etc. No matter which specific type of psychotherapeutic approach is utilized, a supportive, change-oriented environment and good rapport should be established by the therapist. A cognitive-behavioral therapy (CBT) that is client-centered should generally be considered, as it offers a therapy environment tailored to the patient’s need for unconditional acceptance and support. Non-specific factors will likely be an important component of therapy. Therapy should be generally conducted with respect to the client’s pace and level of functioning. Attempts to focus on change too early in therapy could lead to early termination of therapy. This likely occurs because the patient feels the therapist didn’t respect or care enough about him or her to move at their rate.

Psychotherapy approaches for this disorder vary widely. Short-term approaches are preferred, however, because they emphasize realistic, attainable goals in the individual’s life which can usually bring them back to their normal level of functioning. This level, however, may be markedly less than what is expected in the average person. A person who suffers from dysthymic disorder has generally learned to live with a fair amount of chronic unhappiness in their lives. Realistic goals should be established early on and therapy should be the focus, instead of focusing on the person’s mood state.

Group therapy has been shown to be an effective modality for individuals suffering from this disorder. A group can be more supportive of an individual than any one therapist can and help point out inconsistencies in the patient’s thinking and behavior. It should be considered, if not initially, then later on in treatment as the client regains his or her own self-confidence and can interact in a social context. Issues of self-esteem often accompany individuals who have dysthymic disorder, so care must be employed not to place the person into a group situation (where failure may be imminent) too soon. Family therapy may also be helpful for some individuals. Couples therapy can bring the individual’s spouse or significant other into the therapeutic relationship to create a therapeutic (and more powerful) triad.

Goals will vary according to type of therapy. Cognitive therapy emphasizes changes in one’s faulty or distorted way of thinking and perceiving the world. Interpersonal therapy focuses on an individual’s relationships with others and how to improve and strengthen existing relationships while finding new ones. Solution-focused therapy looks at specific problems plaguing an individual’s life in the present and examines how to best go about changing the person’s behavior to solve these difficulties. Social skills training focuses on teaching the client new skills on how to become more effective in social and work relationships. Usually, psychoanalytic and other insight-oriented approaches will be less effective because of their focus on the past and emphasis on lengthy therapy. While incorporation of therapy into a person’s chronic condition might be quite financially lucrative for the therapist, it is not the most change-effective and timely approach to help the individual overcome his or her difficulties.

Because the clinician must move at the client’s pace, progress with any type of therapy can be slow. Therapists should resist the temptation to try and “speed up” the process or force the client in a direction he or she is not yet ready to try. Closely related to this issue of the pace of therapy is being aware of the clinician’s frustration with lack of progress or boredom within the therapy session. It can be an emotionally draining experience for some therapists.

Medications

People with dysthymia often take an antidepressant medication, one that they find helps keep their energy levels up and keep them from reaching the lowest depressive moods. A class of antidepressants called selective serotonin re-uptake inhibitors (SSRIs) are the most commonly prescribed medication for chronic depression today. Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline) and Luvox (fluvoxamine) are the most commonly prescribed brand names. SSRI medications should not be prescribed in conjunction with the older MAOIs (more popular in Europe than in the U.S.).

The large-scale, multi-clinic government research study called STAR*D found that people with depression and who take a medication often need to try different brands and be patient before they find one that works for them.

Results from the STAR*D study indicate that if a first treatment with one SSRI fails, about one in four people who choose to switch to another medication will get better, regardless of whether the second medication is another SSRI or a medication of a different class. And if people choose to add a new medication to the existing SSRI, about one in three people will get better. It appears to make some — but not much — difference if the second medication is an antidepressant from a different class (e.g., bupropion) or if it is a medication that is meant to enhance the SSRI (e.g., buspirone).

The most commonly prescribed antidepressants generally take 6 to 8 weeks before a person will start feeling their therapeutic effects.

Self-Help

Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Adjunctive community support groups in concurrence with psychotherapy is usually beneficial to most people who suffer from dysthymic disorder. Caution should be utilized, however, if the person also suffers from social anxiety. A group like A.A. or N.A. may also be appropriate, if the underlying cause of the dysthymia is a substance abuse problem. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings.

Patients can be encouraged to try out new coping skills, assertiveness skills, cognitive restructuring, etc. within such a support group. They can be an important part of expanding the individual’s skill set and develop new, healthier social relationships.

Since this is a chronic disorder, your mental health professional should be sensitive to not using previous treatment approaches (especially medication) which have proven ineffective in the past. A careful and thorough history should be conducted at the onset of treatment to ensure this is evaluated. Specific attention should also be given to diagnostic issues, such as the existence of an alcohol or substance abuse problem, or social anxiety or other phobia, underlying or causing the dysthymic condition.

Dysthymia Treatment