Clinical features and diagnostic considerations

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By definition, individuals with cyclothymia report short cycles of depression and hypomania that fail to meet the sustained duration criterion for major affective syndromes. At various times, they exhibit the entire range of manifestations required for the diagnosis of depression and hypomania, but only from a few days at a time up to 1 week, rarely longer. (79) These cycles follow each other in an irregular fashion, often changing abruptly from one mood to another, with only rare interposition of 'even' periods. The unpredictability of mood swings is a major source of distress for cyclothymes, as they do not know from moment to moment, how they will feel.(80) As one patient put it, 'my moods swing like a pendulum, from one extreme to another'. The rapid mood shifts, which undermine the patients' sense of self, may lead to the misleading diagnostic label of borderline personality. But unlike a personality disorder, the mood changes in cyclothymes have a circadian component. One patient described it as follows: 'I would go to bed in a cheerful mood and wake up down in the dumps'. This observation is in line with psychophysiological data on mood-switching occurring out of the rapid eye movement sleep phase, as reported in more typical cases of manic depression. (81)

The mood swings of cyclothymes are biphasic: eutonia versus anergic periods; people-seeking versus self-absorption; sharpened thinking versus mental paralysis. Table s provides an empirically tested set of criteria. In addition, the following presentations characterize their roller-coaster biography.

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Table 5 Discriminatory biphasic characteristics of cyclothymic disorder

Irritable periods

At one time or another, labile angry or irritable moods are observed in virtually all these patients. (80) Cyclothymes, unlike patients with epilepsy, are aware of their 'fits of anger', which lead to considerable personal and social embarrassment after they subside. The patients often feel 'on edge, restless, and aimlessly driven'; family and friends report that during these periods patients seem inconsiderate and hostile toward people around them. The contribution of alcohol and sedative-hypnotic drugs to these moods cannot be denied, but the moods often occur in the absence of drugs. Electroencephalography typically reveals no seizure or subseizure activity. The interpersonal costs of such unpredictable interpersonal explosiveness can be quite damaging. One of our patients reported frequent periods where he would start unprovoked fights with very close friends, only to shift into periods of prolonged 'soul-searching, guilt, shame, and embarrassment'. In other patients, outbursts of anger are 'reactive' to minor interpersonal disputes (82)—but once in full force, they are like emotional avalanches with the distinct potential to destroy relationships. Should they dominate the clinical picture, especially among young women who hurt themselves in response to interpersonal contexts, the problematic diagnosis of borderline personality disorder is often invoked (more so in North America than elsewhere). Although controversial, contemporary research suggests that many 'borderline' patients represent a severe labile-irritable variant of cyclothymia on the border of manic-depressive psychosis. (1 8 ,84) On the other hand, bizarre episodes of self-harm, recurrent illusions, and dissociative symptoms of the post-traumatic stress disorder type are uncharacteristic of cyclothymia, and suggest other diagnoses.

Romantic-conjugal failure

It is easy to understand how individuals with mercurial moods would charm others when in an expansive people-seeking mode, and rapidly alienate them when dysphoric. In effect, the life of many of these patients is a tempestuous chain of intense but brief romantic liaisons, (80) often with a series of unsuitable partners. Some rationalize their behaviour on the grounds that their spouse or partner is 'too conservative in sex, too unimaginative, too unaware of the intensity' needed to stimulate them. As expected, frequent marital separations, divorces, and remarriage to the same person occur.

Uneven school and work record

Repeated and unpredictable shifts in work and study habits occur in most people with cyclothymia, giving rise to a dilettante biography. (7 80) Although some do better during their 'high' periods—for example, one car salesman would sell cars only 'when up'—for others, the occasional 'even' periods were more conducive to meaningful work. It is sometimes unappreciated by clinicians inexperienced with bipolarity that the hypomanic period can be one of disorganized and unpatterned busyness that could easily lead to a serious drop in net productivity. For instance, one insurance salesman related that he was less successful when 'high', because he tended to enter into unproductive arguments with his clients. When 'down', productivity obviously abates, although two creative individuals in our case series*80—one inclined poetically, the other towards painting—produced their better work when coming out of mini-depressions.

Alcohol and drug abuse

An alternating pattern of the use of 'uppers' and 'downers' occurs in at least 50 per cent of patients. (Z9> We have clinically evaluated at least five cyclothymes who

'sold dope' to maintain their habit: two went to prison. These and other observations (8 86 and 87> suggest that a proportion of substance-abusing, especially stimulant-abusing, patients might be suffering from subtle or cryptic forms of bipolar disorder. The bipolar nature of mood swings in alcohol- or substance-abusing individuals can be documented by demonstrating mood swings well past the period of detoxification; in some cases, escalating mood instability makes its first appearance following abrupt drug or alcohol withdrawal. The DSM-IV criteria for drug-induced or drug withdrawal-induced mood disorder are, in our opinion, biased against the diagnosis of otherwise treatable bipolar spectrum disorders. (8>

Financial extravagance

One patient in our case series reported going to bars and buying people drinks because he wanted everybody to feel like him. Another patient intermittently showered his lovers with expensive jewellery. In general, however, the extravagance of the cyclothymic group reflects gregariousness and tends to occur on a smaller scale compared to the psychotic manner in which manic patients bring financial ruin to themselves and their families.

The social warmth observed among most people with cyclothymia distinguishes them from adult attention-deficit hyperactivity disorder ( ADHD). Also, elation and inflated self-confidence, which occur periodically in cyclothymia, are uncharacteristic of ADHD; the moodiness in the latter is largely depressive in nature. Finally, antidepressants and stimulants typically worsen the moods in cyclothymia; they treat ADHD. In rare cases, however, cyclothymia and ADHD coexist. (8°)

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