Cyclothymic Disorder DSM-5 301.13 (F34.0)
DSM-5 Category: Mood Disorders
Cyclothymic Disorder is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis assigned to individuals who experience mood cycling over a two year period, but have not met the diagnostic criteria for Bipolar I, Bipolar II, or Depressive disorder. There are a number of rule-outs to consider, and there is debate among clinician and researchers if cyclothymic disorder is a discrete disease process, a temperamental variation,or a premorbid syndrome for Bipolar I or II (Baldessarini, Vázquez, & Tondo, 2011) as 15% to 50% of individuals with cyclothymic will develop either condition (American Psychiatric Association, 2013). Cyclothymic disorder can be diagnosed in adolescents and children, and can be reliably discriminated between other childhood mental health disorders (Van Meter & Youngstrom, 2012). The diagnosis of cyclothymia, bipolar I or II, or a Depressive disorder should considered with clinical skepticism, increasingly more so with younger children. Adolescents and children are prone to labile mood, emotional dyscontrol, and overreacting to minor stressors and disappoints as they do not yet have adult coping skills. It is a fallacy to project adults behavioral norms on to children and adolescents and pathologize age appropriate and typical behaviors.
Symptoms of Cyclothymic Disorder
According to the DSM-5, there are six diagnostic criterion, with one specifier:
- For at least a two year period, there have been episodes of hypomanic and depressive experiences which do not meet the full DSM-5 diagnostic criteria for hypomania or major depressive disorder.
- The above criteria had been present at least half the time during a two year period, with not more than two months of symptom remission.
- There is no history of diagnoses for manic, hypomanic, or a depressive episode.
- the symptoms in criterion A are cannot be accounted for by a psychotic disorder, such as schizophrenia, schizoaffective disorder, schizophrenifrom disorder, or delusional disorder.
- The symptoms cannot be accounted for by substance use or a medical condition.
- The symptoms cause distress or significant impairment in social or occupational functioning.
A specifier the clinician can add is With anxious distress.
The disorder can also be diagnosed in children or adolescents, but the observational period for symptoms is one year rather than two. (American Psychiatric Association, 2013).
The DSM-5 notes that the typical onset of Cyclothymic Disorder is in adolescence or early adulthood, though it can appear in children (American Psychiatric Association, 2013).
According to the DSM-5, the lifetime prevalence of Cyclothymic Disorder is .04% to 1%. It's prevalence is roughly equal in males and females. (American Psychiatric Association, 2013).
The DSM-5 indicates that risk factors for Cyclothymic Disorder are having a first degree relative with bipolar I (American Psychiatric Association, 2013).
The DSM-5 indicates that Cyclothymic Disorder is comorbid with substance abuse disorders (see Differential Diagnosis) as individuals with mood disorders may use drugs or alcohol in an effort to self medicate and quell symptoms. Comorbidity has also been found sleep disorders involving poor onset and maintenance of sleep. In children , there is comorbidity with ADD/ADHD ( Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder), however this must be considered carefully by the clinician ( see Introduction). (American Psychiatric Association, 2013).
Treatment for Cyclothymic Disorder
The DSM-5 does not specify treatment options for Cyclothymic Disorder (American Psychiatric Association, 2013). The use of mood stabilizers, such as Lithium carbonate in conjunction with CBT (Cognitive Behavioral Therapy) and support groups can manage symptoms. (Baldessarini, Vázquez, & Tondo, 2011). Support groups can emphasize medication compliance, and coping with symptoms.
Impact on Functioning
Cyclothymic Disorder can impact social and occupational functioning. (American Psychiatric Association, 2013). Individuals with recurring episodes of depressive or hypomanic/manic symptoms can have difficulty maintaining employment due to absenteeism, poor performance, or erratic behavior in the workplace. Social functioning can be effected by erratic and inappropriate behavior.
There are diagnostic rule-outs for the clinician to consider. In the DSM -5, disorders such as Bipolar I or III with rapid cycling, Borderline Personality Disorder, and substance abuse disorders are possible differential diagnoses. In Bipolar I and II, the alternating hypomanic, manic, and depressive episodes will typically cycle over a period of months or weeks, although more rapid cycling is possible, and the delineation and severity of symptoms may not be as apparent. In Borderline Personality Disorder, the individual may experience a labile mood, which is of different quality than cyclothymic disorder, in that mood will be unstable, and can change from anger, to sadness, to anxiety all within a span of minutes. In substance use disorders, CNS (Central Nervous System) stimulants such as cocaine and methamphetamine will elevate mood, resulting in what appear to be manic or hypomanic symptoms, followed by a corresponding parasympathetic rebound effect resulting in pseudo-depressive symptoms. CNS depressants are also sometimes used in conjunction with stimulants to modulate parasympathetic rebound. This can present an ambiguous diagnostic picture, as those who are substance dependent will typically go to great lengths to hide their use from family and associations. For an accurate diagnoses, once substance use disorder has been established, the individual should be verified drug and alcohol free for at least six months through objective measures such as enzyme-immunoassay urine toxicology screening and observation. If the mood symptoms persist, than a diagnosis of a mood disorder should be considered.
Medical conditions such as hypothyroidism or hyperthyroidism can produce mood cycling. In hypothyroidism, T4 ( thyroxine) and T3, ( triodothyronine) levels are low, and the thyroid gland is less sensitive to TSH ( Thyroid Stimulating Hormone). This can result in depressive symptoms, including lethargy, fatigue, and depressed mood (Hage & Azar, 2012). High thyroid hormone levels can produce anxiety, mania and insomnia, however, overt or sub-clinical hypothyroidism has also been found to commonly occur in people with bipolar disorder, particularly rapid cycling type bipolar disorder ( Chakrabarti, 2011).
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.
Baldessarini, R.J., and Vázquez, G. Tondo, L . ( 2011). Treatment of Cyclothymic Disorder: Commentary. Psychotherapy Psychosomatic. 80:131–135. DOI: 10.1159/000322234. Retrieved March 4, 2014 from
Chakrabarti, S. (2011). Thyroid Functions and Bipolar Affective Disorder . Journal of Thyroid Research. Article ID 306367, http://dx.doi.org/10.4061/2011/306367 .
Hage, M.P., and Azar, S.T. (2012). The Link between Thyroid Function and Depression Journal of Thyroid Research. Article ID 590648. http://dx.doi.org/10.1155/2012/590648
Paderewski , A. (2011). Pediatric cyclothymia is distinct subtype of bipolar disorder .Journal of Affective Disorders. Retrieved March 22, 2014, from http://www.medwirenews.com/47/91584/Psychiatry/Pediatric_cyclothymia_is_distinct_subtype_of_bipolar_disorder_.html
Van Meter, A.R., and Youngstrom E.A. (2012). Cyclothymic disorder in youth: why is it overlooked, what do we know and where is the field headed? Neuropsychiatry (London). 2(6): 509–519. doi: 10.2217/npy.12.64 PMCID: PMC3609426 NIHMSID: NIHMS437143
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