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DSM-II

In DSM-II, this disorder is called Cyclothymic personality

This behavior pattern is manifested by recurring and alternating periods of depression and elation. Periods of elation may be marked by ambition, warmth, enthusiasm, optimism, and high energy. Periods of depression may be marked by worry, pessimism, low energy, and a sense of futility. These mood variations are not readily attributable to external circumstances. If possible, the diagnosis should specify whether the mood is characteristically depressed, hypomanic, or alternating.

DSM-III

Diagnostic Criteria

A. During the past two years, numerous periods during which some symptoms characteristic of both the depressive and the manic syndromes were present, but were not of sufficient severity and duration to meet the criteria for a major depressive or manic episode.

B. The depressive periods and hypomanic periods may be separated by periods of normal mood lasting as long as months at a time, they may be intermixed, or they may alternate.

C. During depressive periods there is depressed mood or loss of interest or pleasure in all or almost all, usual activities and pastimes, and at least three of the following:

  1. insomnia or hypersomnia
  2. low energy or chronic fatigue
  3. feelings of inadequacy
  4. decreased effectiveness or productivity at school, work, or home
  5. decreased attention, concentration, or ability to think clearly
  6. social withdrawal
  7. loss of interest in or enjoyment of sex
  8. restriction of involvement in pleasurable activities; guilt over past activities
  9. feeling slowed down
  10. less talkative than usual
  11. pessimistic attitude toward the future, or brooding about past events
  12. tearfulness or crying

During hypomanic periods there is an elevated, expansive, or irritable mood and at least three of the following:

  1. decreased need for sleep
  2. more energy than usual
  3. inflated self-esteem
  4. increased productivity, often associated with unusual and self-imposed working hours
  5. sharpened and unusually creative thinking
  6. uninhibited people-seeking (extreme gregariousness)
  7. hypersexuality without recognition of possibility of painful consequences
  8. excessive involvement in pleasurable activities with lack of concern for the high potential for painful consequences, e.g., buying sprees, foolish business investments, reckless driving
  9. physical restlessness
  10. more talkative than usual
  11. overoptimism or exaggeration of past achievements
  12. inappropriate laughing, joking, punning

D. Absence of psychotic features such as delusions, hallucinations, incoherence, or loosening of associations.

E. Not due to any other mental disorder, such as partial remission of Bipolar Disorder. However, Cyclothymic Disorder may precede Bipolar Disorder.

Differential Diagnosis

When a major depressive or manic episode is superimposed on Cyclothymic Disorder, both diagnoses should be made because it is likely that the individual will continue to have Cyclothymic Disorder after recovery from the Major Affective Disorder.

DSM-IV

Diagnostic Criteria

A. For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode. Note: In children and adolescents, the duration must be at least 1 year.

B. During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms in Criterion A for more than 2 months at a time.

C. No Major Depressive Episode, Manic Episode, or Mixed Episode has been present during the first 2 years of the disturbance.

Note: After the initial 2 years (1 year in children and adolescents) of Cyclothymic Disorder, there may be superimposed Manic or Mixed Episodes (in which case both Bipolar I Disorder and Cyclothymic Disorder may be diagnosed) or Major Depressive Episodes (in which case both Bipolar II Disorder and Cyclothymic Disorder may be diagnosed).

D. The symptoms in Criterion A are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

E. The symptoms are not 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).

F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Differential Diagnosis

Mood Disorder Due to a General Medical Condition

Cyclothymic Disorder must be distinguished from a Mood Disorder Due to a General Medical Condition. The diagnosis is Mood Disorder Due to a General Medical Condition, With Mixed Features, when the mood disturbance is judged to be the direct physiological consequence of a specific, usually chronic general medical condition (e.g., hyperthyroidism). This determination is based on the history, laboratory findings, or physical examination. If it is judged that the depressive symptoms are not the direct physiological consequence of the general medical condition, then the primary Mood Disorder is recored (e.g., Cyclothymic Disorder) and the general medical condition is recorded separately. This would be the case, for example, if the mood symptoms are considered to be the physiological consequence of having a chronic general medical condition or if there is no etiological relationship between the mood symptoms and the general medical condition.

Substance-Induced Mood Disorder

A Substance-Induced Mood Disorder is distinguished from Cyclothymic Disorder by the fact that a substance (especially stimulants) is judged to be etiologically related to the mood disturbance. The frequent mood swings that are suggestive of Cyclothymic Disorder usually dissipate following cessation of drug use.

Other Bipolar Disorders

Bipolar I Disorder, With Rapid Cycling, and Bipolar II Disorder, With Rapid Cycling, both may resemble Cyclothymic Disorder by virtue of the frequent marked shifts in mood. By definition, the mood states in Cyclothymic Disorder do not meet the full criteria for a Major Depressive, Manic, or Mixed Episode, whereas the specifier With Rapid Cycling requires that full mood episodes be present. If a Major Depressive, Manic, or Mixed Episode occurs during the course of an established Cyclothymic Disorder, the diagnosis of either Bipolar I Disorder (for a Manic or Mixed Episode) or Bipolar II Disorder (for a Major Depressive Episode) is given along with the diagnosis of Cyclothymic Disorder.

Borderline Personality Disorder

Borderline Personality Disorder is associated with marked shifts in mood that may suggest Cyclothymic Disorder. If the criteria are met for each disorder, both Borderline Personality Disorder and Cyclothymic Disorder may be diagnosed.

DSM-5

Diagnostic Criteria

A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.

B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.

C. Criteria for a major depressive, manic, or hypomanic episode have never been met.

D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

  • With anxious distress

Specifiers

Anxious Distress Specifier

The presence of at least two of the following symptoms during the majority of days of the current or most recent episode of mania, hypomania, or depression:

  1. Feeling keyed up or tense.
  2. Feeling unusually restless.
  3. Difficulty concentrating because of worry.
  4. Fear that something awful may happen.
  5. Feeling that the individual might lose control of himself or herself.

Specify current severity:

  • Mild: Two symptoms.
  • Moderate: Three symptoms.
  • Moderate-severe: Four or five symptoms.
  • Severe: Four or five symptoms with motor agitation.

Note: Anxious distress has been noted as a prominent feature of both bipolar and major depressive disorder in both primary care and specialty mental health settings. High levels of anxiety have been associated with higher suicide risk, longer duration of illness, and greater likelihood of treatment nonresponse. As a result, it is clinically useful to specify accurately the presence and severity levels of anxious distress for treatment planning and monitoring of response to treatment.

Differential Diagnosis

Bipolar and related disorder due to another medical condition and depressive disorder due to another medical condition

The diagnosis of bipolar and related disorder due to another medical condition or depressive disorder due to another medical condition is made when the mood disturbance is judged to be attributable to the physiological effect of a specific, usually chronic medical condition (e.g., hyperthyroidism). This determination is based on the history, physical examination, or laboratory findings. If it is judged that the hypomanic and depressive symptoms are not the physiological consequence of the medical condition, then the primary mental disorder (i.e., cyclothymic disorder) and the medical condition are coded. For example, this would be the case if the mood symptoms are considered to be the psychological (not the physiological) consequence of having a chronic medical condition, or if there is no etiological relationship between the hypomanic and depressive symptoms and the medical condition.

Substance/medication-induced bipolar and related disorder and substance/medication-induced depressive disorder

Substance/medication-induced bipolar and related disorder and substance/medication-induced depressive disorder and distinguished from cyclothymic disorder by the judgement that a substance/medication (especially stimulants) is etiologically related to the mood disturbance. The frequent mood swings in these disorders that are suggestive of cyclothymic disorder usually resolve following cessation of substance/medication use.

Bipolar I disorder, with rapid cycling, and bipolar II disorder, with rapid cycling

Both disorders may resemble cyclothymic disorder by virtue of the frequent marked shifts in mood. By definition, in cyclothymic disorder the criteria for a major depressive, manic, or hypomanic episode has never been met, whereas the bipolar I disorder and bipolar II disorder specifier "with rapid cycling" requires the full mood episodes be present.

Borderline personality disorder

Borderline personality disorder is associated with marked shifts in mood that may suggest cyclothymic disorder. If the criteria are met for both disorders, both borderline personality disorder and cyclothymic disorder may be diagnosed.

Related Criteria

Manic Episode

These criteria must have never been met:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:

  1. Inflated self-esteem or grandiosity.
  2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
  3. More talkative than usual or pressure to keep talking.
  4. Flight of ideas or subjective experience that thoughts are racing.
  5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
  6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
  7. 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).

C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition. (Note: A full manic episode that emerges during antidepressant treatment [e.g., medication, electroconvulsive therapy] but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.)

Hypomanic Episode

These criteria must have never been met:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.

B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior, and have been present to a significant degree:

  1. Inflated self-esteem or grandiosity.
  2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
  3. More talkative than usual or pressure to keep talking.
  4. Flight of ideas or subjective experience that thoughts are racing.
  5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
  6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
  7. 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).

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others.

E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.

F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment). (Note: A full hypomanic episode that emerges during antidepressant treatment [e.g., medication, electroconvulsive therapy] but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms [particularly increased irritability, edginess, or agitation following antidepressant use] are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis).

Major Depressive Episode

These criteria must have never been met:

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (Note: Do not include symptoms that are clearly attributable to another medical condition.)

  1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
  3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
  4. Insomnia or hypersomnia nearly every day.
  5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down).
  6. Fatigue or loss of energy nearly every day.
  7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or another medical condition.