What is cyclothymia?
There cyclothymia, or cyclothymic disorder, is one form chronic is milder of bipolar disorder. With the latter, in fact, it falls within the spectrum of mood disturbances and it differs from it for the chronicity and the lower intensity of the symptoms. It is classified, with dysthymia (chronic mild depression), among the persistent affective disorders.
It is a pathology that, as it is nuanced, does not always come to medical attention, yet it occupies a precise place in the classification of DSM-IV (The American Association of Psychiatry Diagnostic Manual):
- Major depressive disorder
- Dysthymic disorder
- Bipolar disorder (itself divided into type I and type II bipolar disorder)
- Cyclothymic disorder
Cyclothymia usually occurs in early adulthood and, if it does not develop into bipolar disorder (which occurs in 15-50% of cases), it is difficult to diagnose.
Symptoms of cyclothymia
It is important to remember that when it comes to disorder, refers to a condition in which the symptoms persist for a long time: bipolar disorder and cyclothymia are both classified among the disturbances bipolar because they present in continuous alternation peaks euphoric mood e deep depressive episodes. More precisely, in the case of bipolar disorder we have real episodes of mania and major depression; in cyclothymic disorder we find mild depression (which we can also call dysthymia) and, at the peaks, hypomania. The latter is a milder form of mania (i.e. a state of euphoria involving multiple aspects of the personality).
It is therefore intuitive that the symptoms of cyclothymia will change depending on which one is talking about dysthymic phase you hate euphoric phase.
Symptoms of the euphoric phase (hypomania)
At this stage, at least 3 of the following symptoms must be present and persistent.
- Hypertrophic self-esteem: the subject has a notable and disproportionate self-esteem;
- Reduced need for sleep: for example, feeling rested after only 3 hours of sleep;
- Increased talkativeness or drive continues to talk
- Difficulty concentrating
- Marked feeling of well-being, physical and mental efficiency;
- Hyperactive behavior (from a social, work, scholastic point of view ...) and a state of perennial agitation;
- Flight of ideas: the subject feels the sensation that thoughts are happening too quickly;
- Involvement in risky activities (overspending, rash business, etc.)
In this phase, relatives or friends of the affected patient notice a clear and unusual change in his way of acting in several areas of daily life, which however does not lead to a serious impairment of work skills, nor does it lead to complete social rejection.
Symptoms of the dysthymic phase
They are those typically found in the dysthymia. In particular we remember:
- Depressed mood for most of the day
- Low self-esteem;
- Pessimism and feelings of despair;
- Hyperphagia or Hyporexia (respectively increased or decreased appetite);
- Asthenia (feeling of weakness) or low energy
- Difficulty making decisions.
The clinical picture can also result in episodes of major depression and episodes of mania, thus leading to a bipolar disorder overt.
The cyclothymic subject therefore experiences destabilizing mood swings due to the passage from the hypomanic to the dysthymic phase. In everyday life, this manifests itself in the planning of ambitious, enthusiastic projects, then suddenly abandoned with the onset of dysthymia; or with the inconstancy in working life and relationships.
It is common that in the dysthymic phase they are amply affected by the negative consequences of the euphoric one (for example, financial problems due to reckless investments). Although these symptoms are more nuanced than what is found in bipolar disorder, such an unfriendly mood is deleterious and exhausting for those affected and those around them.
Causes of cyclothymia
What is the origin of cyclothymia? As for other mood disorders, also for cyclothymia several factors contribute to the origin of the disease and are genetic, biological and social.
Genetic model: the risk of developing cyclothymia is greater than 10% in first degree relatives of subjects with bipolarity or cyclothymia. The hereditary component in the etiology of bipolar spectrum disorders (hereditary bipolarism) is substantial and greater than in any other psychiatric disorder.
Biological model: the nervous system plays a central role in the origin and mechanisms of cyclothymia. This network of signals, at the base of our movements as well as of our thoughts, moods and behaviors, is very complex and delicate. It follows that an alteration of the neurochemical balances affects the mood, the rhythms of sleep and consequently the symptoms. In the specific case of the euphoric phases of the disorder, at the base of the imbalance there would be an increase in levels of noradrenaline, serotonin is dopamine (neurotransmitters of the class of monoamines). On the contrary, in the dysthymic phase there is a defect in the functioning of these neurotransmitters. This is important for drug therapy and also because some drugs, by stimulating the release of monoamines, can exacerbate the symptoms of hypomania.
Social model: the social environment, stress and particularly significant events can encourage the onset of a hypomanic episode.
Diagnosis of cyclothymic disorder
Fundamental is to exclude that at the origin of the disorder, especially hypomania, there isabuse substances or thyroid dysfunction (specifically, hyperthyroidism). The doctor can make a diagnosis of exclusion by prescribing:
- Toxicological screening in blood and urine;
- Liver function;
- Thyroid function (TSH; fT3 and fT4);
- Renal function (azotemia, creatininemia);
- Test and dosage of copper in urine (to rule out autoimmune or genetic diseases that could cause mood changes);
Routine exams are also useful to one preliminary assessment depending on drug therapy, as some drugs may interfere with heart, kidney and liver function or be poorly tolerated by the patient.
Excluding organic or abuse causes, the next step towards diagnosis will be one psychological evaluation of the patient and an anamnesis (i.e. a collection of information and sensations that could be useful in clarifying the clinical picture) that also involves family members, given the importance of the genetic component in the etiology of the disorder.
Psychological assessment for manic episodes also uses test specific for the evaluation of manic episodes: one of these is the YMRS (acronym for Young Mania Rating Scale), an eleven multiple choice questionnaire used by psychiatrists to assess the extent of manic or hypomanic episodes in children and young adults. The test is based on the patient's subjective perceptions of his symptoms up to the previous 48 hours. The questionnaire allows to differentiate, based on the score obtained, hypomania from the most severe mania and, consequently, helps in differential diagnosis between cyclothymia and bipolar disorder. The test has been adapted to self-assessment and is also available as an online test, but it should be emphasized that it is more reliable if done by an expert.
Finally, i must be satisfied to confirm the diagnosis criteria provided by DSM-IV:
- Feedback from numerous hypomanic episodes for at least two years (one year for children and adolescents), alternating with mild depressive symptomswho do not meet the criteria for the diagnosis of Major Depressive Episode;
- During this interval, the symptoms do not cease for more than two months;
- During the first two years of the illness, no Major Depressive Episode or Manic Episode was reported.
- The symptoms are not part of other psychiatric pathologies (such as other mood disorders or schizophrenia).
- The symptoms are not attributable to substance abuse or underlying medical conditions.
- Symptoms cause significant distress to the individual and affect their social and work life.
There is one care effective for cyclothymia? The treatment for cyclothymic disorder it is both pharmacological that psychological.
It is important to educate the patient and family members about the course of the disease and the symptoms. The patient will have to learn to recognize the signs of relapse and stop the harmful behaviors (for example, the use of drugs) that could incentivize them. Understanding and correcting dysfunctional behaviors are also one of the targets of psychotherapy, which will help the patient manage critical episodes and the resulting stress. It also makes use of family therapy is group therapy. The latter can prove to be an excellent support for the patient.
For drug therapy to be successful it is essential that the patient follows it willingly and with precision: some drugs (lithium, for example) have a long-term effect and taking them inconsistently can give important relapses. It will be the doctor's task to inform the cyclothymic patient of the side effects and recommend some precautions regarding the diet and the interaction of therapy with other drugs (even simple analgesics), which could cause organic complications.
The classes of drugs used for the treatment of cyclothymia are the same as in bipolar disorder, what will change will be the dosage.
- Mood stabilizers:
- Lithium: for the treatment of hypomanic episodes and long-term prevention. It is the drug of first choice if there is the intention on the part of the patient to take it for at least three years. Dosage depends on the patient's kidney function and drug formulation. Thyroid function, possible pregnancies and cardiac function (via ECG) should also be checked.
- Valproic acid is Lamotrigine: they are also anticonvulsants (i.e. used to prevent seizures caused by seizures) which can replace or add to lithium.
- Carbamazepine: it is used in cases resistant to treatment. Its use will be monitored with blood tests and other checks due to the multiple side effects.
- Antipsychotics: they are used when mood stabilizers have not been effective.
- Anxiolytics: they are prescribed to restore a correct sleep-wake cycle.