Cyclothymia: Readings from MEDLINE

Compiled by, Ivan Goldberg, MD

J Clin Psychol. 2008 Apr;64(4):501-18.

Restructuring mood in cyclothymia using cognitive behavior therapy: an intensive
time-sampling study.

Totterdell P, Kellett S.

Institute of Work Psychology, University of Sheffield, Sheffield, UK.
p.totterdell@sheffield.ac.uk

Hypotheses predicting how cognitive behavioral therapy (CBT) would change the
daily pattern of mood and sleep in a patient with cyclothymia were formulated
based on circadian processes. Using a prospective single-case experimental
design, the patient provided mood ratings every 4 hours and sleep reports daily
for 49 weeks, including a 4-week baseline, a 20-session CBT intervention, and a
follow-up period. Improvements in mood during and after therapy were accounted
for by reduced daily mood variability and extended sleep. The patient’s energy at
different times of day was explained by adjusting the endogenous rhythm in a
mathematical circadian model. Treatment of cyclothymia and related bipolar
disorders may be enhanced by integrating understanding of circadian mood
regulation into CBT treatment.
J Clin Psychol. 2008 Apr;64(4):482-500.

Lifestyle regularity and cyclothymic symptomatology.

Shen GH, Sylvia LG, Alloy LB, Barrett F, Kohner M, Iacoviello B, Mills A.

Psychology Department, Temple University, Philadelphia, PA 19122, USA.

The social zeitgeber theory emphasizes the importance that social rhythm
regularity may play in promoting internal synchronization of circadian rhythms in
individuals with or at risk for bipolar spectrum disorders. This study examined
the relationship of lifestyle regularity, affective symptomatology, and sleep in
71 individuals exhibiting cyclothymic mood and behavior patterns. Participants
were randomly assigned to either an experimental group in which they were
encouraged to regulate their daily routines or to a control group. Participants
in the experimental group were able to successfully regulate their daily
schedules. Although relationships between regularity and severity of depressive
symptoms, across-day variances in mood and behavior, and sleep duration were
identified during baseline, increased lifestyle regularity did not differentially
result in changes in these variables.
J Psychiatr Res. 2007 Dec 12. [Epub ahead of print]

Hypomanic, cyclothymic and hostile personality traits in bipolar spectrum
illness: A family-based study.

Savitz J, van der Merwe L, Ramesar R.

Division of Human Genetics, Institute of Infectious Disease and Molecular
Medicine, University of Cape Town, South Africa.

OBJECTIVES: To examine hypomanic, cyclothymic and hostile personality traits in a
large, euthymic, family-based group of individuals with bipolar disorder (BPD)
and their affectively ill and healthy relatives. To test whether these traits
follow a distribution with the most “pathological” scores in the bipolar disorder
I (BPD I) group and the least “pathological” scores in the unaffected relatives.
METHODS: Two-hundred and ninety-six individuals from 47 bipolar disorder families
were administered a battery of personality questionnaires (Temperament Evaluation
of Memphis, Pisa, Paris, and San Diego; Temperament and Character Inventory;
Affective Neuroscience Personality Scale; Hypomanic Personality Scale; Borderline
Traits Questionnaire) as well as a self-rating depression (Beck Depression
Inventory) and mania (Altman Self-Rating Mania) scale. Out of the 296
participants, 57 were diagnosed with BPD I, 24 with bipolar disorder II (BPD II),
58 with recurrent major depression (MDE-R), 45 had one previous depressive
episode (MDE-S), and 86 were unaffected. Twenty six individuals had another
DSM-IV diagnosis. RESULTS: The BPD I group displayed elevated hypomanic,
cyclothymic and hostile traits. These traits were also characteristic of the BPD
II group but were less salient in the MDE-R group. The MDE-S group did not differ
significantly from unaffected relatives. Hypomanic personality characteristics
were clearly elevated in both BPD groups and differentiated BPD from major
depressive disorder (MDD) individuals. CONCLUSIONS: Our results provide
preliminary support for the hypothesis that temperament is a genetically
quantitative trait.
Am J Med Genet B Neuropsychiatr Genet. 2008 Apr 5;147(3):326-32.

Suggestive linkage of a chromosomal locus on 18p11 to cyclothymic temperament in
bipolar disorder families.

Evans LM, Akiskal HS, Greenwood TA, Nievergelt CM, Keck PE Jr, McElroy SL,
Sadovnick AD, Remick RA, Schork NJ, Kelsoe JR.

Department of Psychiatry, Columbia University, New York, New York, USA.

Attempts to identify bipolar disorder (BP) genes have only enjoyed limited
success. One potential cause for this problem is that the traditional categorical
BP phenotypes currently used in genetic linkage studies are not the most
informative, efficient, or biologically relevant. An alternative to these strict
categorical BP phenotypes is quantitative BP phenotypes. By isolating one aspect
of a complex trait such as BP into a simple, intermediate, quantitative trait,
genes that contribute to the larger complex trait can be more readily identified.
Along these lines, we utilized a temperament-based measure (cyclothymic
temperament) as a quantitative, intermediate BP phenotype in linkage analyses and
hypothesized that this measure might more efficiently detect loci for BP or
temperamental traits that predispose to BP. A total of 158 individuals with
temperament data from 28 BP families were used in the linkage analyses. All
pedigrees had a proband diagnosed with BPI or BPII and at least two other family
members with a mood disorder diagnosis. An 8 cM genome scan was performed and
analyzed using MERLIN nonparametric multipoint regression linkage for a
cyclothymic temperament trait. The highest overall LOD score was on chromosome 18
(LOD = 2.71, P = 0.0002). Other linkage peaks which may indicate potential
regions of interest were found on chromosomes 3 and 7. The temperament-based
cyclothymic trait yielded a higher peak LOD score and a lower P-value than
analyses using traditional, categorical phenotypes in a separate analysis
including these same families. Copyright 2007 Wiley-Liss, Inc.
J Affect Disord. 2008 Jun;108(3):207-16. Epub 2008 Feb 20.

Dissociative experiences differentiate bipolar-II from unipolar depressed
patients: the mediating role of cyclothymia and the Type A behaviour speed and
impatience subscale.

Oedegaard KJ, Neckelmann D, Benazzi F, Syrstad VE, Akiskal HS, Fasmer OB.

Department of Clinical Medicine, Section for Psychiatry, Faculty of Medicine,
University of, Bergen, Bergen, Norway. koedegaa@ucsd.edu

BACKGROUND: Dissociative symptoms are often seen in patients with mood disorders,
but there is little information on possible association with subgroups and
temperamental features of these disorders. METHODS: The Dissociative Experience
Scale was administered to 85 patients with a DSM-IV Major Depressive Disorder
(MDD) or Bipolar-II Disorder (BP-II). Both broad-spectrum dissociation (DES total
score) and clearly pathological forms of dissociation (DES-Taxon) were assessed.
Temperament was assessed using Akiskal and Mallya;s criteria of Affective
Temperaments and the Jenkins Activity Survey (JAS) for Type A Behaviour. RESULTS:
Sixty-five patients gave valid answers to DES. The mean DES and DES-T scores were
higher in BP-II (16.8 and 12.7 respectively) compared to MDD (9.0 and 5.7); DES
odds ratio (OR)=1.58 (95% CI 1.15-2.18) and DES-T OR=1.60 (95% CI 1.14-2.25)
using univariate logistic regression analyses. There was no significant
difference in DES score in patients with (n=30) and without an affective
temperament (n=35): mean (95% CI), 13.5 vs. 10.5 (-7.8 to 1.9), p=0.224. However
the subgroup with a cyclothymic temperament (n=18) had higher DES scores (mean
(95% CI): 17.8 vs. 9.7 (2.9-13.3), p=0.003), compared to patients without such a
temperament. There was no significant difference in DES scores for patients with
(n=35) or without (n=28) a Type A behaviour pattern (JAS>0): mean (95% CI) 12. 7
vs. 10.9 (-6.8 to 3.3), p=0.491), but a positive JAS factor S score (speed and
impatience subscale) was associated with significantly higher DES scores than a
negative S-score: mean (95% CI) 14.9 vs. 9.0 (1.1-10.7), p=0.017), and this was
still significant (p=0.005) using multiple linear regression of DES scores vs.
the JAS subscale scores. DES-T scores were significantly higher in patients with
OCD (n=9) (mean (95% CI) 18.4 vs. 6.6 (6.0-17.7), p<0.001); eating disorder
(n=13) (14.0 vs. 6.8 (1.8-12.6), p=0.009), psychotic symptoms during depressions
(n=9) (16.6 vs. 6.9 (3.7-15.8), p=0.002), and in those with a history of suicide
attempt (n=28) (11.9 vs. 5.4 (2.2-10.8), p=0.003), but only OCD was an
independent predictor after multiple linear regression of DES-T scores vs. all
co-morbid disorders (p=0.043). LIMITATIONS: The major limitation of the present
study is a non-blind evaluation of affective diagnosis and temperaments, and
assessment in a non-remission clinical status. CONCLUSIONS: Dissociative symptoms
measured with the Dissociative Experience Scale are associated with bipolar
features, using formal DSM-IV criteria, cyclothymic temperament and the speed and
impatience subscale of the JAS.
J Affect Disord. 2006 May;92(1):91-7. Epub 2006 Jan 24.

Bulimia nervosa in atypical depression: the mediating role of cyclothymic
temperament.

Perugi G, Toni C, Passino MC, Akiskal KK, Kaprinis S, Akiskal HS.

Department of Psychiatry, Neurobiology, Pharmacology and Biotechnologies,
Psychiatry Section, University of Pisa, Pisa, Italy. gperugi@psico.med.unipi.it

OBJECTIVE: Recent data indicate significant clinical, biological, and treatment
response overlap between eating and bipolar disorders, especially when soft
symptoms of either spectrum disorders are considered. The aim of the present
analyses is to evaluate the lifetime prevalence of bulimia nervosa (BN) in
patients with atypical depression (AD) and to delineate any demographic,
clinical, personality or temperamental factors that may characterize this
subgroup. METHOD: We examined in a semi-structured format 107 consecutive
patients who met DSM-IV criteria for major depressive episode with atypical
features and we separated them into two groups according to the co-occurring
criteria for BN. They were further evaluated on the basis of the Atypical
Depression Diagnostic Scale (ADDS), the Hopkins Symptoms Check-list (HSCL 90),
and the Hamilton Rating Scale for Depression (HRSD), coupled with its modified
form for reverse vegetative features, as well as Axis I and II comorbidity and
temperamental dispositions. RESULTS: Seventeen (17.8%) percent of AD met the
DSM-IV criteria for Bulimia Nervosa (BN+). These patients, compared with those
who did not meet criteria for BN (BN-), were indistinguishable on all demographic
and most psychopathologic and clinical features (including bipolar I and II), but
were significantly higher in lifetime comorbidity for Narcissistic, Histrionic,
Borderline and Dependent personality disorders as well as that for Cyclothymic
temperament. BN+ also scored higher on the ADDS items of reactivity of mood and
interpersonal sensitivity. LIMITATIONS: Correlational clinical study in which
doctors could not be entirely blind to the variables under investigation.
CONCLUSIONS: Cyclothymic temperament and related mood reactivity and
interpersonal sensitivity may account for much of the relationship between AD and
BN. Narcissistic, histrionic and borderline traits, too, seem to be related to
the presence of a cyclothymic disposition. The data overall, in particular the
cyclothymic reactivity in the absence of differences in BP-I and II, all support
the hypothesis that places BN in the “ultra-soft” bipolar realm.
J Affect Disord. 2006 Dec;96(3):233-7.

Erratum in:
J Affect Disord. 2008 Jan;105(1-3):315.

Toward a definition of a cyclothymic behavioral endophenotype: which traits tap
the familial diathesis for bipolar II disorder?

Hantouche EG, Akiskal HS.

Université Paris VI Mood Center, Hôpital Pitiè-Salpêtrière, Paris, France.

BACKGROUND: Although the cyclothymic temperament appears to be related to the
familial diathesis of bipolar disorder, exhibiting high sensitivity for bipolar
II (BP-II) disorder, it is presently uncertain which of its constituent traits
are specific for this disorder. METHODS: In a sample of 446 major depressive
patients (BP-II and unipolar), in the French National EPIDEP study, the
cyclothymic temperament was assessed by using clinician- and self-rated scales.
We computed the frequency of individual traits and relative risk for family
history of bipolarity. RESULTS: From both clinician- and self-rated scales, four
items related to mood reactivity, energy, psychomotor and mental activity were
significantly highly represented in the subgroup with positive family history of
bipolarity. The item “rapid shifts in mood and energy” obtained the highest
relative risk (OR=3.42) for positive family history of bipolarity. CONCLUSION:
These findings delineate those cyclothymic traits which are most likely to tap a
familial-genetic diathesis for BP-II, thereby identifying traits which can best
serve as a behavioral endophenotype for this bipolar subtype. Such an
endophenotype might underlie the cyclic course of bipolar disorder first
described in France 150 years ago by Falret and Baillarger.
J Affect Disord. 2006 Dec;96(3):177-81.

Cyclothymia and labile personality: is all folie circulaire?

van Valkenburg C, Kluznik JC, Speed N, Akiskal HS.

Department of Psychiatry 116A, VA Southern Nevada Healthcare System, North Las
Vegas, NV 89036, USA.

BACKGROUND: Historically, cyclothymia has been used broadly to refer either to a
temperament (Kretschmer) or the entire range of bipolar disorders. Within this
spectrum, it is uncertain whether it characterizes the “hard” (or
manic-depressive) forms (as Kurt Schneider argued) or its “soft” expressions
(bipolar II and highly recurrent depressions); the latter perspective is in line
with Falret’s view that the melancholic expressions of his folie circulaire
(circular insanity) were highly prevalent in the community. METHODS: Eight
hundred forty-three outpatients were interviewed with the Schedule for Affective
Disorders and Schizophrenia without regard to hierarchical exclusionary rules.
RESULTS: Compared to 630 psychiatrically interviewed outpatients who did not have
cyclothymia, 163 cyclothymics were significantly more likely to have most of the
disorders listed in the SADS in univariate analyses. Discriminant analyses
limited the significant associations to labile personality, bipolar II,
intermittent depression, secondary depression, hypomanic disorder and
schizoaffective mania. LIMITATION: The RDC construct of cyclothymia is rather
broad. CONCLUSIONS: Despite such operational breadth, cyclothymia was nonetheless
largely limited to the soft end of the bipolar spectrum where labile moods and
depressive recurrence predominate. In this sense, it is natural to place it on
the border of manic-depressive psychosis. Although Kurt Schneider was the first
to describe the “labile psychopath” [personality], he believed it was unrelated
to his narrow concept of cyclothymia, which he used synonymously with
manic-depressive psychosis. Our data do not support his position. Instead, they
support both Kretchmer’s and Falret’s views.
J Affect Disord. 2005 Mar;85(1-2):181-9.

Cyclothymic temperament as a prospective predictor of bipolarity and suicidality
in children and adolescents with major depressive disorder.

Kochman FJ, Hantouche EG, Ferrari P, Lancrenon S, Bayart D, Akiskal HS.

Department of Child and Adolescent Psychiatry, Unit 59I13, 304 Avenue Motte,
59100 Roubaix, France. fkochman@voila.fr

INTRODUCTION: Although several recent studies suggest that bipolar disorder most
commonly begins during childhood or adolescence, the illness still remains
under-recognized and under-diagnosed in this age group. As part of the French
Bipolar network and in line with the hypothesis that juvenile depression is
pre-bipolar , we evaluated the rate of onset of bipolar disorders in a
naturalistic 2-year prospective study of consecutive, clinically depressed
children and adolescents, and to test whether the cyclothymic temperament
underlies such onset. METHODS: Complete information was obtained from both
parents and patients in 80 of 109 depressed children and adolescents assessed
with Kiddie-SADS semi-structured interview, according to DSM IV criteria. They
were also assessed with a new questionnaire on cyclothymic-hypersensitive
temperament (CHT) from the TEMPS-A cyclothymic scale adapted for children
(provided in ), and other assessment tools including the Child Depression
Inventory (CDI), Young Mania Rating Scale, Clinical Global Assessment Scale
(CGAS), and Overt Aggressive Scale (OAS). RESULTS: Of the 80 subjects, 35 (43%)
could be diagnosed as bipolar at the end of the prospective follow-up. This
outcome was significantly more common in those with cyclothymic temperament
measured at baseline. Most of these patients were suffering from a special form
of bipolar disorder, characterized by rapid mood shifts with associated conduct
disorders (CD), aggressiveness, psychotic symptoms and suicidality. LIMITATION:
The primary investigator, who took care of the patients clinically, was not blind
to the clinical and psychometric data collected. Since all information was
collected in a systematic fashion, the likelihood of biasing the results was
minimal. CONCLUSION: We submit that the CHT in depressed children and adolescents
heralds bipolar transformation. Unlike hypomanic or manic symptoms, which are
often difficult to establish in young patients examined in cross-section or by
history, cyclothymic traits are detectable in childhood. Our data underscore the
need for greater effort to standardize the diagnosis and treatment of pre-bipolar
depressions in juvenile patients.
J Affect Disord. 2005 Mar;85(1-2):135-45.

The cyclothymic temperament in healthy controls and familially at risk
individuals for mood disorder: endophenotype for genetic studies?

Chiaroni P, Hantouche EG, Gouvernet J, Azorin JM, Akiskal HS.

Service de Psychiatrie, Hôpital Sainte Marguerite, Bd. Sainte-Marguerite, 13009
Marseille, France. pierre.chiaroni@wanadoo.fr

BACKGROUND: The modern concept of affective disorders focuses increasingly on the
study of subthreshold conditions on the border of manic or depressive episodes.
Indeed, a spectrum of affective conditions spanning from temperament to clinical
episodes has been proposed by the senior author. As bipolar disorder is a
familial illness, an examination of cyclothymic temperament (CT) in controls and
relatives of bipolar patients is of major relevance. METHODS: We recruited a
total sample of 177 healthy symptom-free volunteers. These controls were divided
into three groups. The first one is comprised of 100 normal subjects with a
negative familial affective history (NFH); the second of 37 individuals, with
positive affective family history (PFH); and a third of 40 subjects, with at
least one sib or first-degree kin with bipolar disorder type I according to the
DSM-IV (BPR). The last two groups defined at risk individuals. We interviewed all
subjects with CT, as described by the senior author. RESULTS: We found a
statistically significant difference in the rates of CT between the subjects in
BPR versus others. CT was also more prevalent in the PFH compared with NFH.
Additionally, the simple numeration of the CT traits exhibited gradation in the
distribution of individuals inside the NFH, PFH and BPR. Finally, categorically
defined CT and CT traits predominated in females. LIMITATION and CONCLUSION:
Although not all relatives of bipolar probands were studied, our results exhibit
an aggregation of CT in families with affective disorder-and more specifically
those with bipolar background. These results allow us to propose the importance
of including CT for phenotypic characterization of bipolar disorder. Furthermore,
our results support a spectrum concept of bipolar disorder, whereby CT is
distributed in ascending order in the well-relatives of those with depressive and
bipolar disorders. We submit that this temperament represents a behavioral
endophenotype, serving as a link between molecular and behavioral genetics.
J Affect Disord. 2005 Feb;84(2-3):259-66.

Sustained remission with lamotrigine augmentation or monotherapy in female
resistant depressives with mixed cyclothymic-dysthymic temperament.

Manning JS, Haykal RF, Connor PD, Cunningham PD, Jackson WC, Long S.

From Mood Clinic, Family Medicine Department, University of Tennessee, Memphis,
TN, USA. smanning1@triad.rr.com

BACKGROUND: The treatment of bipolar depression remains problematic. Lamotrigine
has been shown in randomized controlled studies to be efficacious in preventing
bipolar depression and rapid cycling states. METHODS: Twenty-four women with
cyclothymic temperament and refractory depression were recruited from four
outpatient sites (three primary care and one psychiatric) and treated with
lamotrigine in a naturalistic, open-label study. Temperament was determined by
responses on the TEMP-A self-rating scale. Eighteen (75%) of these cyclothymic
patients also scored high on the depressive temperament. Eighteen (75%) met
DSM-IV criteria for bipolar II disorder. In two thirds of the cases, lamotrigine
was add-on therapy to an antidepressant. Response to therapy was assessed using
the DSM-IV Global Assessment of Functioning (GAF). LIMITATIONS: This study was
naturalistic in design, without controls or blinds. RESULTS: Of the 23 patients
who remained in the study, 16 (70%) had significant, sustained responses. Of
these 16, 12 (75% of responders, 52% of the total) had remissions (GAF > 80)
sustained longer than 12 months. Robust, sustained responses to lamotrigine
monotherapy were seen in 4 patients (17%). Seven patients (30%) received no
apparent benefit from lamotrigine. CONCLUSIONS: Lamotrigine induced prolonged
illness remissions in a substantial number of female patients whose symptoms were
both complex and refractory. Most manifested high scores on the cyclothymic and
depressive temperaments, and prior refractoriness to multiple antidepressant and
antidepressant/mood stabilizer combinations, before remitting with lamotrigine
augmentation or monotherapy.
Hist Psychiatry. 2003 Sep;14(55 Pt 3):377-99.

Cyclothymia, a circular mood disorder.

Baethge C, Salvatore P, Baldessarini RJ.

Ewald Hecker (1843-1909) was a collaborator of Karl Ludwig Kahlbaum (1828-1899).
Both worked outside the university and public mental institutions of Germany. By
meticulously observing clinical signs and illness-course, they laid the
groundwork for modern descriptive psychiatry. Their clinical approach influenced
Kraepelin and continues to dominate psychiatric classification. Hecker
popularized several of Kahlbaum’s syndromal concepts, including hebephrenia.
Another was cyclothymia, a relatively benigh form of manic-depressive illness,
introduced by Kahlbaum, in 1882. It included depressive (dysthymia), hypomanic
(hyperthymia), and mixed hypomanic-depressive phases. The Kahlbaum-Hecker
syndrome of cyclothymia survives in DSM-IV bipolar II disorder and cyclothymia.
An annotated English translation of Hecker’s 1898 paper is provided, with
historical notes on Hecker and the significance of his work.
Seishin Shinkeigaku Zasshi. 2003;105(5):533-43.

[Cyclothymia and typus melancholicus: empirical study on personality character of
mood disorder] [Article in Japanese]

Akiyama T, Tsuda H, Matsumoto S, Kawamura Y, Miyake Y.

Department of Psychiatry, Kanto Medical Center NTT, Tokyo, Japan.

PURPOSE: 1. To investigate whether depressive, cyclothymic, hyperthymic and
irritable temperaments as identified by TEMPS-A are characteristic to monopolar
or bipolar disorder. 2. To investigate the independency and to discuss the
clinical validity of the temperaments. 3. To replicate the previous studies
whether Typus Melancholicus is characteristic to monopolar disorder. 4. To
investigate the relationship between Typus Melancholicus and mood dysregulation,
and the relationship, if any, is characteristically observed with monopolar
disorder. 5. To discuss the difference between monopolar and bipolar disorder in
terms of personality character. SAMPLE: Monopolar and bipolar groups were
recruited consecutively from the patients who received outpatient treatment at
Kanto Medical Center between September and November, 2001. The age is between 18
and 60. The exclusion criteria were psychotic disorder, organic disorder, grave
physical illness and non-remitted mood symptoms (HRSD > 11 and MRS > 13). Control
group was selected from 1391 company employees who participated in TEMPS-A
research project between May 2001 and May 2002, matching gender and age with
monopolar and bipolar groups. The exclusion criterion was marked depressive
symptom (CES-D > 16). STATISTICAL ANALYSIS: The statistical analyses were done
with Kruskal-Wallis test and Mann-Whitney U test with Bonferroni’s correction
regarding the difference among the groups. Spearman coefficients were examined
regarding the independency of temperaments. The relationship between Typus
Melancholicus and mood dysregulation was examined by mono-regression analysis.
RESULT AND DISCUSSION: Depressive and cyclothymic temperaments scores did not
differ significantly between monopolar and bipolar. These scores were
significantly higher in monopolar and bipolar than in control. Therefore, these
temperaments are evidenced to be characteristic with mood disorder. But between
monopolar and bipolar there was no significant difference. Irritable temperament
score did not differ significantly among the three groups. This score showed a
highly significant correlation with cyclothymic and depressive temperaments.
Irritable temperament seems closely related with the personality character of
mood disorder, however this temperament itself was not characteristic.
Hyperthymic temperament score was mildly significantly lower in bipolar than in
control. There was no other significant inter-group difference. This temperament
hardly showed a correlation with other temperaments. Though hyperthymic
temperament may be hypothesized characteristic with manic patients, the result
did not support this hypothesis. Typus Melancholicus score did not differ
significantly among three groups. This result contradicts with a number of
previous studies. It seems that the prevalence of Typus Melancholicus among the
groups should be further investigated. Typus Melancholicus showed a mild
correlation with depressive temperament in monopolar and with depressive,
cyclothymic and irritable and temperaments in bipolar. Regarding mono-regression
analysis, no temperament predicted Typus Melancholicus formation in monopolar.
Depressive, cyclothymic and irritable temperaments predicted significantly in
bipolar. In control group, hyperthymic temperament predicted midly significantly,
but the prediction rate was as small as 7%. These results seem to support the
theories of Shimoda and Matussek that Typus Melancholicus characters are related
with bipolar disorder. Between monopolar and bipolar, there was not much
significant difference in terms of personality characteristics. This seems to
suggest no marked personality character difference between these groups and
supports Akiskal’s concept of Bipolar Spectrum. CONCLUSION: 1. Depressive and
Cyclothymic temperaments are characteristic with mood disorder. 2. Hyperthymic
temperament is independent, but not characteristic with mood disorder. 3.
Irritable temperament may be modifying the personality character of mood
disorder. 4. Typus Melancholicus was not characteristic to monopolar disorder. 5.
Significant relationship between Typus Melancholicus and mood dysregulation was
observed in bipolar group. 6. There seems no substantial difference between
monopolar and bipolar disorders in terms of personality character.
J Affect Disord. 2003 Jun;75(1):1-10.

Cyclothymic OCD: a distinct form?

Hantouche EG, Angst J, Demonfaucon C, Perugi G, Lancrenon S, Akiskal HS.

Mood Center, Department of Psychiatry, Pitié-Salpêtrière Hospital, 47 Bd de
l’Hôpital, 75013 Paris, France. hantouch@noos.fr

BACKGROUND: Clinical research on the comorbidity of obsessive compulsive disorder
(OCD) and other anxiety disorders has largely focused on depression. However in
practice, resistant or severe OCD patients not infrequently suffer from a masked
or hidden comorbid bipolar disorder. METHOD: The rate of bipolar comorbidity in
OCD was systematically explored among 453 members of the French Association of
patients suffering from OCD (AFTOC) as well as a psychiatric sample of OCD
out-patients (n=175). As previous research by us has shown the epidemiologic and
clinical sample to be similar, we combined them in the present analyses (n=628).
To assess mood disorder comorbidity, we used structured self-rated questionnaires
for major depression, hypomania and mania (DSM-IV criteria), self-rated Angst’s
checklist of Hypomania and that for the Cyclothymic Temperament (French version
developed by Akiskal and Hantouche). RESULTS: According to DSM-IV definitions of
hypomania/mania, 11% of the total combined sample was classified as bipolar (3%
BP-I and 8% BP-II). When dimensionally rated, 30% obtained a cut-off score >/=10
on the Hypomania checklist and 50% were classified as cyclothymic. Comparative
analyses were conducted between OCD with (n=302) versus without cyclothymia
(n=272). In contrast to non-cyclothymics, the cyclothymic OCD patients were
characterized by more severe OCD syndromes (higher frequencies of aggressive,
impulsive, religious and sexual obsessions, compulsions of control, hoarding,
repetition); more episodic course; greater rates of manic/hypomanic and major
depressive episodes (with higher intensity and recurrence) associated with higher
rates of suicide attempts and psychiatric admissions; and finally, a less
favorable response to anti-OCD antidepressants and elevated rate of mood
switching with aggressive behavior. LIMITATION: Hypomania and cyclothymia were
not confirmed by diagnostic interview by a clinician. CONCLUSION: Our data extend
previous research on “OCD-bipolar comorbidity” as a highly prevalent and largely
under-recognized and untreated class of OCD patients. Furthermore, our data
suggest that “cyclothymic OCD” could represent a distinct form of OCD. More
attention should be paid to it in research and clinical practice.
J Affect Disord. 2003 Jan;73(1-2):87-98.

The role of cyclothymia in atypical depression: toward a data-based
reconceptualization of the borderline-bipolar II connection.

Perugi G, Toni C, Travierso MC, Akiskal HS.

Department of Psychiatry, University of Pisa, Via Roma 67, 56100, Pisa, Italy.
gperugi@pisco.med.unipi.it

OBJECTIVE: Recent data, including our own, indicate significant overlap between
atypical depression and bipolar II. Furthermore, the affective fluctuations of
patients with these disorders are difficult to separate, on clinical grounds,
from cyclothymic temperamental and borderline personality disorders. The present
analyses are part of an ongoing Pisa-San Diego investigation to examine whether
interpersonal sensitivity, mood reactivity and cyclothymic mood swings constitute
a common diathesis underlying the atypical depression-bipolar II-borderline
personality constructs. METHOD: We examined in a semi-structured format 107
consecutive patients who met criteria for major depressive episode with DSM-IV
atypical features. Patients were further evaluated on the basis of the Atypical
Depression Diagnostic Scale (ADDS), the Hopkins Symptoms Check-list (HSCL-90),
and the Hamilton Rating Scale for Depression (HRSD), coupled with its modified
form for reverse vegetative features as well as Axis I and SCID-II evaluated Axis
II comorbidity, and cyclothymic dispositions (‘APA Review’, American Psychiatric
Press, Washington DC, 1992). RESULTS: Seventy-eight percent of atypical
depressives met criteria for bipolar spectrum-principally bipolar II-disorder.
Forty-five patients who met the criteria for cyclothymic temperament, compared
with the 62 who did not, were indistinguishable on demographic, familial and
clinical features, but were significantly higher in lifetime comorbidity for
panic disorder with agoraphobia, alcohol abuse, bulimia nervosa, as well as
borderline and dependent personality disorders. Cyclothymic atypical depressives
also scored higher on the ADDS items of maximum reactivity of mood, interpersonal
sensitivity, functional impairment, avoidance of relationships, other rejection
avoidance, and on the interpersonal sensitivity, phobic anxiety, paranoid
ideation and psychoticism of the HSCL-90 factors. The total number of cyclothymic
traits was significantly correlated with ‘maximum’ reactivity of mood and
interpersonal sensitivity. A significant correlation was also found between
interpersonal sensitivity and ‘usual’ and ‘maximum’ reactivity of mood.
LIMITATION: Correlational study. CONCLUSIONS: Mood lability and interpersonal
sensitivity traits appear to be related by a cyclothymic temperamental diathesis
which, in turn, appears to underlie the complex pattern of anxiety, mood and
impulsive disorders which atypical depressive, bipolar II and borderline patients
display clinically. We submit that conceptualizing these constructs as being
related will make patients in this realm more accessible to pharmacological and
psychological interventions geared to their common temperamental attributes. More
generally, we submit that the construct of borderline personality disorder is
better covered by more conventional diagnostic entities.
J Affect Disord. 2003 Jan;73(1-2):49-57.

Bipolar II with and without cyclothymic temperament: “dark” and “sunny”
expressions of soft bipolarity.

Akiskal HS, Hantouche EG, Allilaire JF.

International Mood Center, UCSD Department of Psychiatry, 9500 Gilman Drive, La
Jolla, San Diego, CA 92093-0603, USA. hakiskal@ucsd.edu

BACKGROUND: In the present report deriving from the French national multi-site
EPIDEP study, we focus on the characteristics of Bipolar II (BP-II), divided on
the basis of cyclothymic temperament (CT). In our companion article (Hantouche et
al., this issue), we found that this temperament in its self-rated version
correlated significantly with hypomanic behavior of a risk-taking nature. Our aim
in the present analyses is to further test the hypothesis that such
patients-assigned to CT on the basis of clinical interview-represent a more
“unstable” variant of BP-II. METHODS: From a total major depressive population of
537 psychiatric patients, 493 were re-examined on average a month later; after
excluding 256 DSM-IV MDD and 41 with history of mania, the remaining 196 were
placed in the BP-II spectrum. As mounting international evidence indicates that
hypomania associated with antidepressants belongs to this spectrum, such
association per se did not constitute a ground for exclusion. CT was assessed by
clinicians using a semi-structured interview based on in its French version; as
two files did not contain full interview data on CT, the critical clinical
variable in the present analyses, this left us with an analysis sample of 194
BP-II. Socio-demographic, psychometric, clinical, familial and historical
parameters were compared between BP-II subdivided by CT. Psychometric measures
included self-rated CT and hypomania scales, as well as Hamilton and Rosenthal
scales for depression. RESULTS: BP-II cases categorically assigned to CT (n=74)
versus those without CT (n=120), were differentiated as follows: (1). younger age
at onset (P=0.005) and age at seeking help (P=0.05); (2). higher scores on HAM-D
(P=0.03) and Rosenthal (atypical depressive) scale (P=0.007); (3). longer delay
between onset of illness and recognition of bipolarity (P=0.0002); (4). higher
rate of psychiatric comorbidity (P=0.04); (5). different profiles on axis II
(i.e., more histrionic, passive-aggressive and less obsessive-compulsive
personality disorders). Family history for depressive and bipolar disorders did
not significantly distinguish the two groups; however, chronic affective
syndromes were significantly higher in BP-II with CT. Finally, cyclothymic BP-II
scored significantly much higher on irritable-risk-taking than “classic”
driven-euphoric items of hypomania. CONCLUSION: Depressions arising from a
cyclothymic temperament-even when meeting full criteria for hypomania-are likely
to be misdiagnosed as personality disorders. Their high familial load for
affective disorders (including that for bipolar disorder) validate the bipolar
nature of these “cyclothymic depressions.” Our data support their inclusion as a
more “unstable” variant of BP-II, which we have elsewhere termed “BP-II 1/2.”
These patients can best be characterized as the “darker” expression of the more
prototypical “sunny” BP-II phenotype. Coupled with the data from our companion
paper (Hantouche et al., 2003, this issue), the present findings indicate that
screening for cyclothymia in major depressive patients represents a viable
approach for detecting a bipolar subtype that could otherwise be mistaken for an
erratic personality disorder. Overall, our findings support recent international
consensus in favoring the diagnosis of cyclothymic and bipolar II disorders over
erratic and borderline personality disorders when criteria for both sets of
disorders are concurrently met.
J Affect Disord. 2003 Jan;73(1-2):39-47.

Factor structure of hypomania: interrelationships with cyclothymia and the soft
bipolar spectrum.

Hantouche EG, Angst J, Akiskal HS.

Psychiatry Department, Mood Center, Pitié-Salpetriere Hospital, Paris, France.

BACKGROUND: No systematic data exists on the phenomenology and psychometric
aspects of hypomania. In this report we focus on the factor structure of
hypomania and its relationships with cyclothymic temperament in unipolar (UP) and
bipolar II (BP-II) spectrum (soft bipolar) patients. METHOD: The combined sample
of UP and BP-II spectrum patients (n=427) derives from the French National
multi-center study (EPIDEP). The study involved training 48 psychiatrists at 15
sites in France in a protocol based on DSM-IV phenomenological criteria for major
depressive disorder, hypomania, and BP-II, as well as a broadened definition of
soft bipolarity. Psychometric measures included Angst’s Hypomania Checklist (HCA)
and Akiskal’s Cyclothymic Temperament (CT) Questionnaires. RESULTS: In the
combined sample of the UP and BP-II spectrum, the factor pattern based on the HCA
was characterized by the presence of one hypomanic component. In the soft bipolar
group (n=191), two components were identified before and after varimax rotation.
The first factor (F-1) identified hypomania with positive (driven-euphoric)
features, and the second factor (F-2) hypomania with greater irritability and
risk-taking. In exploratory analyses, both factors of hypomania tentatively
distinguished most soft BP subtypes from UP. However, F-1 was generic across the
soft spectrum, whereas F-2 was rather specific for II-1/2 (i.e., BP-II arising
from CT). CT, which was found to conform to a single factor among the soft
bipolar patients, was significantly correlated only with irritable risk-taking
hypomania (F-2). LIMITATION: In a study conducted in a clinical setting,
psychiatrists cannot be kept blind of the data revealed in the various clinical
evaluations and instruments. However, the systematic collection of all data
tended to minimize biases. CONCLUSION: EPIDEP data revealed a dual structure of
hypomania with ‘classic’ driven-euphoric contrasted with irritable risk-taking
expressions distributed differentially across the soft bipolar spectrum. Only the
latter correlated significantly with cyclothymic temperament, suggesting the
hypothesis that repeated brief swings into hypomania tend to destabilize soft
bipolar conditions.
Psychiatr Clin North Am. 2002 Dec;25(4):713-37.

The soft bipolar spectrum redefined: focus on the cyclothymic, anxious-sensitive,
impulse-dyscontrol, and binge-eating connection in bipolar II and related
conditions.

Perugi G, Akiskal HS.

Institute of Behavioral Sciences G. De Lisio, Viale Monzone 3, 54031 Carrara,
Italy. g.perugi@psico.med.unipi.it

The bipolar II spectrum represents the most common phenotype of bipolarity.
Numerous studies indicate that in clinical settings this soft spectrum might be
as common–if not more common than–major depressive disorders. The proportion of
depressive patients who can be classified as bipolar II further increases if the
4-day threshold for hypomania proposed by the DSM-IV is reconsidered. The modal
duration of hypomanic episodes is 2 days; highly recurrent brief hypomania is as
short as 1 day, and when complicated by major depression, it should be classified
as a variant of bipolar II. Another variant of the bipolar II pattern is
represented by major depressive episodes superimposed on cyclothymic or
hyperthymic temperamental characteristics. The literature is unanimous in
supporting the idea that depressed patients who experience hypomania during
antidepressant treatment belong to the bipolar II spectrum. So-called alcohol- or
substance-induced mood disorders may have much in common with bipolar II spectrum
disorders, in particular when mood swings outlast detoxification. Finally, many
patients within the bipolar II spectrum, especially when recurrence is high and
the interepisodic period is not free of affective manifestations, may meet
criteria for personality disorders. This is particularly true for cyclothymic
bipolar II patients, who are often misclassified as borderline personality
disorder because of their extreme mood instability. Subthreshold mood lability of
a cyclothymic nature seems to be the common thread that links the soft bipolar
spectrum. The authors submit this to represent the endophenotype likely to be
informative in genetic investigations. Mood lability can be considered the core
characteristics of the bipolar II spectrum, and it has been validated
prospectively as a sensitive and specific predictor of bipolar II outcome in
major depressives. In a more hypothetical vein, cyclothymic-anxious-sensitive
temperamental disposition might represent the mediating underlying characteristic
in the complex pattern of anxiety, mood, and impulsive disorders that bipolar II
spectrum patients display throughout much of their lifetimes. The foregoing
conclusions, based on clinical experience and the research literature, challenge
several conventions in the formal classificatory system (i.e., ICD-10 and
DSM-IV). The authors submit that the enlargement of classical bipolar II
disorders to include a spectrum of conditions subsumed by a
cyclothymic-anxious-sensitive disposition, with mood reactivity and interpersonal
sensitivity, and ranging from mood, anxiety, impulse control, and eating
disorders, will greatly enhance clinical practice and research endeavors.
Prospective studies with the requisite methodologic sophistication are needed to
clarify further the relationship of the putative temperamental and developmental
variables to the complex syndromic patterns described herein. The authors believe
that viewing these constructs as related entities with a common temperamental
diathesis will make patients in this realm more accessible to pharmacologic and
psychological approaches geared to their common temperamental attributes. The
authors submit that the use of the term “spectrum” is distinct from a simple
continuum of subthreshold and threshold cases. The underlying temperamental
dimensions postulated by the authors define the disposition for soft bipolarity
and its variation and dysregulation in anxious disorders and dyscontrol in
appetitive, mental, and behavioral disorders, much beyond affective disorders in
the narrow sense.
Presse Med. 2002 Apr 13;31(14):644-8.

[Cyclothymic obsessive-compulsive disorder. Clinical characteristics of a
neglected and under-recognized entity] [Article in French]

Hantouche EG, Demonfaucon C, Angst J, Perugi G, Allilaire JF, Akiskal HS.

Centre de l’humeur, Département de psychiatrie adulte, Hôpital Pitié-Salpêtrière,
47 bd de l’Hôpital, 75013 Paris. hantouch@noos.fr

OBJECTIVE: Clinical research is largely focused on depressive comorbidity in
obsessional compulsive disorder (OCD). However some recent publications have
suggested that bipolar comorbidity occurs in authentic OCD and its presence has a
differential impact on the clinical picture and course of OCD. METHOD: Recent
data from the collaborative survey conducted with AFTOC (French Association of
patients suffering from OCD) have revealed a high rate of bipolar comorbidity in
OCD: 30% for hypomania and 50% for cyclothymia. RESULTS: The present paper
presents further comparative analyses between OCD with (n = 302) versus without
cyclothymia (n = 272). The sub-group “Cyclothymic OCD” is characterized by a
different clinical picture (higher frequency of aggressive, impulsive, religious
and sexual obsessions, and compulsions of control, hoarding, repetition),
episodic course, higher rate of major depressive episodes (with more intensity
and recurrence) associated with higher rates of suicide attempts and psychiatric
admissions, and less favorable response to anti-OCD treatments. CONCLUSION: These
data suggested that cyclothymic OCD could represent a specific distinct variant
form of OCD. More vigilance is needed toward this entity which is largely
under-recognized in clinical practice.
J Affect Disord. 2001 Jan;62(1-2):17-31.

Dysthymia and cyclothymia in psychiatric practice a century after Kraepelin.

Akiskal HS.

VA Psychiatry Service (116A), 3350 La Jolla Village Drive, San Diego, CA 92161,
USA. hakiskal@ucsd.edu

Kraepelin had a modern vision of affective illness. He hypothesized that
affective recurrences arose from enduring dispositions of depressive,
cyclothymic, irritable, or ‘manic’ types. These dispositions appeared as
‘temperaments’ in English translations of his work. In the extreme, such
temperamental gloominess or moodiness is today officially diagnosed as
‘dysthymic’ or ‘cyclothymic’; irritable and hyperthymic (or manic) dispositions
have not received official sanction in the contemporary psychiatric nomenclature.
This paper reviews recent research which supports Kraepelin’s theoretical
framework regarding dysthymic and cyclothymic dispositions both as clinically
relevant extreme forms of temperament and as precursors of major affective
episodes. Compelling lines of evidence along epidemiologic, clinical-descriptive,
familial-genetic, therapeutic, and follow-up perspectives are summarized for each
disposition. Much of what in contemporary psychiatry is considered to be in the
realm of subthreshold affective conditions, overlaps considerably with
Kraepelin’s concepts of the trait affective dispositions described herein. Most
importantly, although Kraepelin’s observations were based primarily on
hospitalized, severely ill affective patients, his broad vision still guides us
today for understanding etiology and instituting public health and preventive
measures in major affective episodes.
J Affect Disord. 2003 Jan;73(1-2):87-98.

The role of cyclothymia in atypical depression: toward a data-based
reconceptualization of the borderline-bipolar II connection.

Perugi G, Toni C, Travierso MC, Akiskal HS.

Department of Psychiatry, University of Pisa, Via Roma 67, 56100, Pisa, Italy.
gperugi@pisco.med.unipi.it

OBJECTIVE: Recent data, including our own, indicate significant overlap between
atypical depression and bipolar II. Furthermore, the affective fluctuations of
patients with these disorders are difficult to separate, on clinical grounds,
from cyclothymic temperamental and borderline personality disorders. The present
analyses are part of an ongoing Pisa-San Diego investigation to examine whether
interpersonal sensitivity, mood reactivity and cyclothymic mood swings
constitute a common diathesis underlying the atypical depression-bipolar
II-borderline personality constructs. METHOD: We examined in a semi-structured
format 107 consecutive patients who met criteria for major depressive episode
with DSM-IV atypical features. Patients were further evaluated on the basis of
the Atypical Depression Diagnostic Scale (ADDS), the Hopkins Symptoms Check-list
(HSCL-90), and the Hamilton Rating Scale for Depression (HRSD), coupled with its
modified form for reverse vegetative features as well as Axis I and SCID-II
evaluated Axis II comorbidity, and cyclothymic dispositions (‘APA Review’,
American Psychiatric Press, Washington DC, 1992). RESULTS: Seventy-eight percent
of atypical depressives met criteria for bipolar spectrum-principally bipolar
II-disorder. Forty-five patients who met the criteria for cyclothymic
temperament, compared with the 62 who did not, were indistinguishable on
demographic, familial and clinical features, but were significantly higher in
lifetime comorbidity for panic disorder with agoraphobia, alcohol abuse, bulimia
nervosa, as well as borderline and dependent personality disorders. Cyclothymic
atypical depressives also scored higher on the ADDS items of maximum reactivity
of mood, interpersonal sensitivity, functional impairment, avoidance of
relationships, other rejection avoidance, and on the interpersonal sensitivity,
phobic anxiety, paranoid ideation and psychoticism of the HSCL-90 factors. The
total number of cyclothymic traits was significantly correlated with ‘maximum’
reactivity of mood and interpersonal sensitivity. A significant correlation was
also found between interpersonal sensitivity and ‘usual’ and ‘maximum’
reactivity of mood. LIMITATION: Correlational study. CONCLUSIONS: Mood lability
and interpersonal sensitivity traits appear to be related by a cyclothymic
temperamental diathesis which, in turn, appears to underlie the complex pattern
of anxiety, mood and impulsive disorders which atypical depressive, bipolar II
and borderline patients display clinically. We submit that conceptualizing these
constructs as being related will make patients in this realm more accessible to
pharmacological and psychological interventions geared to their common
temperamental attributes. More generally, we submit that the construct of
borderline personality disorder is better covered by more conventional
diagnostic entities.
J Affect Disord. 2003 Jan;73(1-2):49-57.

Bipolar II with and without cyclothymic temperament: “dark” and “sunny”
expressions of soft bipolarity.

Akiskal HS, Hantouche EG, Allilaire JF.

International Mood Center, UCSD Department of Psychiatry, 9500 Gilman Drive, La
Jolla, San Diego, CA 92093-0603, USA. hakiskal@ucsd.edu

BACKGROUND: In the present report deriving from the French national multi-site
EPIDEP study, we focus on the characteristics of Bipolar II (BP-II), divided on
the basis of cyclothymic temperament (CT). In our companion article (Hantouche
et al., this issue), we found that this temperament in its self-rated version
correlated significantly with hypomanic behavior of a risk-taking nature. Our
aim in the present analyses is to further test the hypothesis that such
patients-assigned to CT on the basis of clinical interview-represent a more
“unstable” variant of BP-II. METHODS: From a total major depressive population
of 537 psychiatric patients, 493 were re-examined on average a month later;
after excluding 256 DSM-IV MDD and 41 with history of mania, the remaining 196
were placed in the BP-II spectrum. As mounting international evidence indicates
that hypomania associated with antidepressants belongs to this spectrum, such
association per se did not constitute a ground for exclusion. CT was assessed by
clinicians using a semi-structured interview based on in its French version; as
two files did not contain full interview data on CT, the critical clinical
variable in the present analyses, this left us with an analysis sample of 194
BP-II. Socio-demographic, psychometric, clinical, familial and historical
parameters were compared between BP-II subdivided by CT. Psychometric measures
included self-rated CT and hypomania scales, as well as Hamilton and Rosenthal
scales for depression. RESULTS: BP-II cases categorically assigned to CT (n=74)
versus those without CT (n=120), were differentiated as follows: (1). younger
age at onset (P=0.005) and age at seeking help (P=0.05); (2). higher scores on
HAM-D (P=0.03) and Rosenthal (atypical depressive) scale (P=0.007); (3). longer
delay between onset of illness and recognition of bipolarity (P=0.0002); (4).
higher rate of psychiatric comorbidity (P=0.04); (5). different profiles on axis
II (i.e., more histrionic, passive-aggressive and less obsessive-compulsive
personality disorders). Family history for depressive and bipolar disorders did
not significantly distinguish the two groups; however, chronic affective
syndromes were significantly higher in BP-II with CT. Finally, cyclothymic BP-II
scored significantly much higher on irritable-risk-taking than “classic”
driven-euphoric items of hypomania. CONCLUSION: Depressions arising from a
cyclothymic temperament-even when meeting full criteria for hypomania-are likely
to be misdiagnosed as personality disorders. Their high familial load for
affective disorders (including that for bipolar disorder) validate the bipolar
nature of these “cyclothymic depressions.” Our data support their inclusion as a
more “unstable” variant of BP-II, which we have elsewhere termed “BP-II 1/2.”
These patients can best be characterized as the “darker” expression of the more
prototypical “sunny” BP-II phenotype. Coupled with the data from our companion
paper (Hantouche et al., 2003, this issue), the present findings indicate that
screening for cyclothymia in major depressive patients represents a viable
approach for detecting a bipolar subtype that could otherwise be mistaken for an
erratic personality disorder. Overall, our findings support recent international
consensus in favoring the diagnosis of cyclothymic and bipolar II disorders over
erratic and borderline personality disorders when criteria for both sets of
disorders are concurrently met.
J Affect Disord. 2003 Jan;73(1-2):39-47.

Factor structure of hypomania: interrelationships with cyclothymia and the soft
bipolar spectrum.

Hantouche EG, Angst J, Akiskal HS.

Psychiatry Department, Mood Center, Pitie-Salpetriere Hospital, Paris, France.

BACKGROUND: No systematic data exists on the phenomenology and psychometric
aspects of hypomania. In this report we focus on the factor structure of
hypomania and its relationships with cyclothymic temperament in unipolar (UP)
and bipolar II (BP-II) spectrum (soft bipolar) patients. METHOD: The combined
sample of UP and BP-II spectrum patients (n=427) derives from the French
National multi-center study (EPIDEP). The study involved training 48
psychiatrists at 15 sites in France in a protocol based on DSM-IV
phenomenological criteria for major depressive disorder, hypomania, and BP-II,
as well as a broadened definition of soft bipolarity. Psychometric measures
included Angst’s Hypomania Checklist (HCA) and Akiskal’s Cyclothymic Temperament
(CT) Questionnaires. RESULTS: In the combined sample of the UP and BP-II
spectrum, the factor pattern based on the HCA was characterized by the presence
of one hypomanic component. In the soft bipolar group (n=191), two components
were identified before and after varimax rotation. The first factor (F-1)
identified hypomania with positive (driven-euphoric) features, and the second
factor (F-2) hypomania with greater irritability and risk-taking. In exploratory
analyses, both factors of hypomania tentatively distinguished most soft BP
subtypes from UP. However, F-1 was generic across the soft spectrum, whereas F-2
was rather specific for II-1/2 (i.e., BP-II arising from CT). CT, which was
found to conform to a single factor among the soft bipolar patients, was
significantly correlated only with irritable risk-taking hypomania (F-2).
LIMITATION: In a study conducted in a clinical setting, psychiatrists cannot be
kept blind of the data revealed in the various clinical evaluations and
instruments. However, the systematic collection of all data tended to minimize
biases. CONCLUSION: EPIDEP data revealed a dual structure of hypomania with
‘classic’ driven-euphoric contrasted with irritable risk-taking expressions
distributed differentially across the soft bipolar spectrum. Only the latter
correlated significantly with cyclothymic temperament, suggesting the hypothesis
that repeated brief swings into hypomania tend to destabilize soft bipolar
conditions.
Psychiatr Clin North Am. 2002 Dec;25(4):713-37.

The soft bipolar spectrum redefined: focus on the cyclothymic,
anxious-sensitive, impulse-dyscontrol, and binge-eating connection in bipolar II
and related conditions.

Perugi G, Akiskal HS.

Institute of Behavioral Sciences G. De Lisio, Viale Monzone 3, 54031 Carrara,
Italy. g.perugi@psico.med.unipi.it

The bipolar II spectrum represents the most common phenotype of bipolarity.
Numerous studies indicate that in clinical settings this soft spectrum might be
as common–if not more common than–major depressive disorders. The proportion
of depressive patients who can be classified as bipolar II further increases if
the 4-day threshold for hypomania proposed by the DSM-IV is reconsidered. The
modal duration of hypomanic episodes is 2 days; highly recurrent brief hypomania
is as short as 1 day, and when complicated by major depression, it should be
classified as a variant of bipolar II. Another variant of the bipolar II pattern
is represented by major depressive episodes superimposed on cyclothymic or
hyperthymic temperamental characteristics. The literature is unanimous in
supporting the idea that depressed patients who experience hypomania during
antidepressant treatment belong to the bipolar II spectrum. So-called alcohol-
or substance-induced mood disorders may have much in common with bipolar II
spectrum disorders, in particular when mood swings outlast detoxification.
Finally, many patients within the bipolar II spectrum, especially when
recurrence is high and the interepisodic period is not free of affective
manifestations, may meet criteria for personality disorders. This is
particularly true for cyclothymic bipolar II patients, who are often
misclassified as borderline personality disorder because of their extreme mood
instability. Subthreshold mood lability of a cyclothymic nature seems to be the
common thread that links the soft bipolar spectrum. The authors submit this to
represent the endophenotype likely to be informative in genetic investigations.
Mood lability can be considered the core characteristics of the bipolar II
spectrum, and it has been validated prospectively as a sensitive and specific
predictor of bipolar II outcome in major depressives. In a more hypothetical
vein, cyclothymic-anxious-sensitive temperamental disposition might represent
the mediating underlying characteristic in the complex pattern of anxiety, mood,
and impulsive disorders that bipolar II spectrum patients display throughout
much of their lifetimes. The foregoing conclusions, based on clinical experience
and the research literature, challenge several conventions in the formal
classificatory system (i.e., ICD-10 and DSM-IV). The authors submit that the
enlargement of classical bipolar II disorders to include a spectrum of
conditions subsumed by a cyclothymic-anxious-sensitive disposition, with mood
reactivity and interpersonal sensitivity, and ranging from mood, anxiety,
impulse control, and eating disorders, will greatly enhance clinical practice
and research endeavors. Prospective studies with the requisite methodologic
sophistication are needed to clarify further the relationship of the putative
temperamental and developmental variables to the complex syndromic patterns
described herein. The authors believe that viewing these constructs as related
entities with a common temperamental diathesis will make patients in this realm
more accessible to pharmacologic and psychological approaches geared to their
common temperamental attributes. The authors submit that the use of the term
“spectrum” is distinct from a simple continuum of subthreshold and threshold
cases. The underlying temperamental dimensions postulated by the authors define
the disposition for soft bipolarity and its variation and dysregulation in
anxious disorders and dyscontrol in appetitive, mental, and behavioral
disorders, much beyond affective disorders in the narrow sense.
Presse Med. 2002 Apr 13;31(14):644-8.

[Cyclothymic obsessive-compulsive disorder. Clinical characteristics of a
neglected and under-recognized entity] [Article in French]

Hantouche EG, Demonfaucon C, Angst J, Perugi G, Allilaire JF, Akiskal HS.

Centre de l’humeur, Departement de psychiatrie adulte, Hopital
Pitie-Salpetriere, 47 bd de l’Hopital, 75013 Paris. hantouch@noos.fr

OBJECTIVE: Clinical research is largely focused on depressive comorbidity in
obsessional compulsive disorder (OCD). However some recent publications have
suggested that bipolar comorbidity occurs in authentic OCD and its presence has
a differential impact on the clinical picture and course of OCD. METHOD: Recent
data from the collaborative survey conducted with AFTOC (French Association of
patients suffering from OCD) have revealed a high rate of bipolar comorbidity in
OCD: 30% for hypomania and 50% for cyclothymia. RESULTS: The present paper
presents further comparative analyses between OCD with (n = 302) versus without
cyclothymia (n = 272). The sub-group “Cyclothymic OCD” is characterized by a
different clinical picture (higher frequency of aggressive, impulsive, religious
and sexual obsessions, and compulsions of control, hoarding, repetition),
episodic course, higher rate of major depressive episodes (with more intensity
and recurrence) associated with higher rates of suicide attempts and psychiatric
admissions, and less favorable response to anti-OCD treatments. CONCLUSION:
These data suggested that cyclothymic OCD could represent a specific distinct
variant form of OCD. More vigilance is needed toward this entity which is
largely under-recognized in clinical practice.
6: J Affect Disord. 2001 Jan;62(1-2):17-31.

Dysthymia and cyclothymia in psychiatric practice a century after Kraepelin.

Akiskal HS.

VA Psychiatry Service (116A), 3350 La Jolla Village Drive, San Diego, CA 92161,
USA. hakiskal@ucsd.edu

Kraepelin had a modern vision of affective illness. He hypothesized that
affective recurrences arose from enduring dispositions of depressive,
cyclothymic, irritable, or ‘manic’ types. These dispositions appeared as
‘temperaments’ in English translations of his work. In the extreme, such
temperamental gloominess or moodiness is today officially diagnosed as
‘dysthymic’ or ‘cyclothymic’; irritable and hyperthymic (or manic) dispositions
have not received official sanction in the contemporary psychiatric
nomenclature. This paper reviews recent research which supports Kraepelin’s
theoretical framework regarding dysthymic and cyclothymic dispositions both as
clinically relevant extreme forms of temperament and as precursors of major
affective episodes. Compelling lines of evidence along epidemiologic,
clinical-descriptive, familial-genetic, therapeutic, and follow-up perspectives
are summarized for each disposition. Much of what in contemporary psychiatry is
considered to be in the realm of subthreshold affective conditions, overlaps
considerably with Kraepelin’s concepts of the trait affective dispositions
described herein. Most importantly, although Kraepelin’s observations were based
primarily on hospitalized, severely ill affective patients, his broad vision
still guides us today for understanding etiology and instituting public health
and preventive measures in major affective episodes.
Versicherungsmedizin. 1998 Dec 1;50(6):215-8.

[Dysthymia and cyclothymia–serious consequences of rarely diagnosed disorders] [Article in German]

Brieger P, Marneros A.

Klinik und Poliklinik fur Psychiatrie und Psychotherapie,
Martin-Luther-Universitat Halle-Wittenberg, Halle, Saale.

Dysthymia and cyclothymia are chronic affective disorders with a minimum
duration of 2 years. Both ICD-10 and DSM-IV define cyclothymia as a bipolar
disorder with low intensity. This disorder is rare and little research has been
done on it. Its economic and social consequences vary from case to case. In
contrast dysthymias, chronic depressive disorders, are frequent (prevalence
3-6%) and cause considerable distress. They have serious economic and social
consequences, which are comparable to those caused by other chronic conditions
such as arthritis or diabetes mellitus. Despite widely held conviction a
majority of dysthymias improves under consequent pharmaco- and psychotherapy.
J Affect Disord. 1998 Oct;51(1):7-19.

TEMPS-I: delineating the most discriminant traits of the cyclothymic,
depressive, hyperthymic and irritable temperaments in a nonpatient population.

Akiskal HS, Placidi GF, Maremmani I, Signoretta S, Liguori A, Gervasi R, Mallya
G, Puzantian VR.

International Mood Center, Department of Psychiatry, University of California,
San Diego, USA. hakiskal@ucsd.edu

BACKGROUND: Although most personality constructs have been standardized in
population studies, cyclothymic, depressive, irritable and hyperthymic
temperaments putatively linked to mood disorders have been classically derived
from clinical observations. METHODS: We therefore administered the
semi-structured affective temperament schedule of Memphis, Pisa, Paris and San
Diego, Interview version (TEMPS-I) — in its original University of Tennessee
operationalization — to 1010 Italian students aged between 14 and 26. The
interview, administered in a randomized format, took 20 min per subject.
RESULTS: The semi-structured interview was easy to administer and well accepted
by subjects, with no refusals. Principal component analysis with varimax
rotation confirmed the hypothesized four-dimensional factor structure of the
interview, with good to excellent internal consistency. Furthermore,
discriminant analysis and multiple regression provided suggestions for
identifying the traits that are most useful in defining a weighted cut-off for
each of the temperaments (and which, with minor exceptions, are in agreement
with those previously proposed on clinical grounds). In an additional
exploratory factorial analysis, a depressive type which loads negatively on
hyperthymia was distinguished from cyclothymia; the irritable temperament did
not appear to have significant loading on either factor. LIMITATION: All the
present analyses were internal to the scale itself, but ongoing studies are
comparing them with other systems of temperament as well as testing their
clinical cogency for affectively ill populations. CONCLUSION: While more work
needs to be done on better operationalization of the irritable temperament, our
findings overall support the existence — in a relatively young nonpatient
population — of cyclothymic, depressive and hyperthymic types according to the
classic descriptions of Kraepelin, Kretschmer and Schneider, in their TEMPS-I
operationalization. CLINICAL IMPLICATIONS: Coupled with a previous report
identifying 10% of the same 14-26-year-old nonpatient population meeting an
empirically defined statistical cut-off for these temperaments, the present data
define the putative ‘fundamental states’ that Kraepelin considered to be the
personal predisposing anlage of major affective disorders.
J Affect Disord. 1998 Sep;50(2-3):215-24.

The high prevalence of bipolar II and associated cyclothymic and hyperthymic
temperaments in HIV-patients.

Perretta P, Akiskal HS, Nisita C, Lorenzetti C, Zaccagnini E, Della Santa M,
Cassano GB.

Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology,
University of Pisa, Italy.

BACKGROUND: Although recent studies have shown high rates of current and
lifetime depression in HIV-infected patients, there is little systematic data on
the occurrence of bipolarity in these patients. METHOD: We compared 46 HIV
patients with index major depressive episode (MDE) to an equal number of age-
and sex-matched seronegative MDE patients, and systematically examined rates of
DSM-III-R bipolar subtypes (enriched in accordance with Akiskal’s system of
classifying soft bipolar disorders). RESULTS: Although HIV and psychiatric
clinic patients had comparable background in terms of familial affective
loading, HIV patients had significantly higher familial rates for alcohol and
substance use. The more important finding was the significantly higher
proportion of HIV patients with lifetime bipolar II disorder (78%), and
associated cyclothymic (52%) and hyperthymic (35%) temperaments; the findings
were the same irrespective of HIV risk status (intravenous drug user vs.
homosexual and other risk groups combined). LIMITATIONS: The major methodologic
limitation of our study is that clinicians evaluating temperament were not blind
to affective diagnoses and family history. The comparison affective group was a
sample of convenience drawn from the same tertiary care university facility.
CONCLUSION: The finding of a high rate of bipolar II disorder in HIV patients
has treatment implications for seropositive patients presenting with depression.
More provocatively, we submit that premorbid impulsive risk-taking traits
associated with cyclothymic and hyperthymic temperaments may have played an
important role in needle-sharing drug use and/or unprotected sexual behavior,
leading ultimately to infection with HIV. Given their public health importance,
these clinical findings and insights merit further investigation. In particular,
systematic case-control studies, as well as other large scale studies with
prospective methodology need to be conducted.
J Neurol Neurosurg Psychiatry. 1997 Dec;63(6):796-7.

Seasonal cyclothymia to seasonal bipolar affective disorder: a double switch
after stroke.

Kumar S, Jacobson RR, Sathananthan K.

PRiSM, Institute of Psychiatry, London, UK.

The appearance of bipolar affective disorder after stroke depends on the
presence of two factors: a predisposing factor of either genetic loading or
subcortical atrophy, and a lesion of specific corticolimbic pathways involving
the right hemisphere. Whether cyclothymia and seasonal affective disorder
further predispose to poststroke affective disorder is not clear. A case is
described which highlights these issues. The aetiological factors,
pathophysiology, and diagnosis are discussed.
J Affect Disord. 1997 Sep;45(3):117-26.

Dysthymia and cyclothymia: historical origins and contemporary development.

Brieger P, Marneros A.

Psychiatric Hospital, Martin Luther University, Halle-Wittenberg, Germany.
peter.brieger@medizin.uni-halle.de

The aim of this article is to review and put in their historical context today’s
data, methodologies and concepts concerning subaffective disorders. The historic
roots of dysthymic and cyclothymic disorders–part of the subaffective
spectrum–are essentially Greek, but the first use of the word ‘dysthymia’ in
psychiatry was by C.F. Flemming in 1844. E. Hecker introduced the term
‘cyclothymia’ in 1877. K.L. Kahlbaum (1882) further developed the concepts of
hyperthymia, cyclothymia and dysthymia–with possible subthreshold
symptomatology–in 1882. After Kraepelin’s rubric of ‘manic-depressive
insanity’, the term ‘dysthymia’ was widely forgotten, and ‘cyclothymia’ became
ill defined. Nowadays the latter term is used in three, partially contradictory,
senses: (1) a synonym for bipolar disorder (K. Schneider), (2) a temperament (E.
Kretschmer) and (3) a subaffective disorder (DSM-IV, ICD-10). A renaissance of
subaffective disorders began with the development of DSM-III. Therapeutically
important research has focused on dysthymic disorder and its relationship to
major depressive disorder, while cyclothymic disorder is relatively neglected;
nonetheless, operationalized as a subaffective dimension or temperament,
cyclothymia appears to be a likely precursor or ingredient of the construct of
bipolar II disorder.
Nervenarzt. 1997 Jul;68(7):531-44.

[What is cyclothymia?] [Article in German]

Brieger P, Marneros A.

Klinik und Poliklinik fur Psychiatrie und Psychotherapie,
Martin-Luther-Universitat Halle-Wittenberg.

The term “cyclothymia” is being used with different meanings. DSM-IV and ICD-10
define “cyclothymia” or “cyclothymic disorder” as a long lasting, subeffective
disorder with frequent shifts between hypomanic and (sub)depressive states. In
the tradition of Kurt Schneider cyclothymia was understood as a synonym for
manic-depressive illness exclusively, while different personality typologies
speak of a “cyclothymic” typus. Historically, the term was first used by the
German psychiatrist Ewald Hecker in 1877. The definitions of DSM-IV and ICD-10
seem to be satisfactory in respect to reliability, but the nosological position
of “cyclothymic disorder” is unclear. We review results concerning clinical
symptomatology, comorbidity, biological parameters, personality (including the
question of creativity), psycho- and pharmacotherapy as well as clinical course,
which leave many questions open. Nevertheless, results in family studies support
the idea that at least a fraction of “cyclothymia” is a mild or subclinical form
of bipolar disorders. Until further research, which is urgently needed, we
suggest that the term “cyclothymia” should be only used according to the
guidelines of DSM-IV and ICD-10.
Prog Neuropsychopharmacol Biol Psychiatry. 1996 Nov;20(8):1325-39.

20-year chronobiologic study of a middle-aged cyclothymic male subject.

Goodman DA.

Newport Neuroscience Center San Marcos, California, USA.

1. Cyclothymia is characterized by pronounced but not debilitating shifts of
moods often lasting approximately two to nine weeks. 2. It can be classified as
a psychopathologic mood disorder on a continuum to Bipolar II, or as a
chronobiologic rhythm similar to the circadian except on an infradian time
scale. 3. A male subject diagnosed cyclothymic agreed to daily chart moods and
emotions, record dreams and monitor physical states. He kept track of
hypomania-depression, high-low energy, high-low tension, dream affect and sleep
parameters. 4. In the 1,006 affective cycles recorded between 1977 and 1996,
four affective phases appeared sequentially: being comparable to early hypomania
(I, PA), late hypomania (II, PD), early depression (III, ND) and late depression
(IV, NA). 5. During the experiment lasting 20 years, the frequency of the
four-phase affective cycle increased intermittently from 30.3 days (1977) to
28.0 days (1980), 24.7 days (1983), 19.0 days (1986), 17.8 days (1989), 12.1
days (1992), and 1.3 days (1995). 6. These findings of a four-phase variable
infradian rhythm may have utility in determining fine structure and time course
of rhythms in cyclothymics, both medicated and non-medicated, studied outside
the clinical laboratory.
J Clin Psychiatry. 1994 Apr;55 Suppl:46-52.

Dysthymic and cyclothymic depressions: therapeutic considerations.

Akiskal HS.

Department of Psychiatry, University of California at San Diego, La Jolla
92093-0603.

This paper reviews recent evidence on two prevalent course patterns of major
depressive illness arising from dysthymic and cyclothymic temperamental
substrates. The first pattern, known as “double depression,” typically begins
insidiously in childhood or adolescence, pursues a low-grade intermittent
course, and is complicated by superimposed highly recurrent major depressions.
Patients with this pattern respond to TCAs, MAOIs (classical and reversible),
and SSRIs (of which the best current evidence is for fluoxetine). The second
pattern, that of “cyclothymic depression,” is represented by bipolar II and
related soft bipolar disorders; it pursues a more fluctuating course from onset
in juvenile or early adult years, and appears susceptible to rapid cycling upon
tricyclic antidepressant administration. For patients exhibiting the latter
pattern, bupropion, MAOIs, and low-dose SSRIs all seem beneficial, but should be
preferably used in conjunction with lithium or other mood stabilizers such as
valproate; thyroid augmentation is particularly relevant to these cyclothymic
depressions. Practical and supportive psychotherapeutic approaches would be
useful for double depressive patients, while psychoeducation and attention to
rhythmopathy would be more relevant for those with cyclothymic depressions.
Conjugal and other interpersonal strains should also be addressed in both
affective subtypes. The evidence reviewed does not support the commonly held
belief that depressions associated with “personality” disorders respond
suboptimally to treatment. On the contrary,the temperamental dysregulation
underlying depressive subtypes defined by course appears responsive–even
overresponsive–to a new spectrum of thymoleptic agents. These considerations
underscore the close link between innovative temperament-based classifications
of depressive illness and emerging clinical management strategies with
thymoleptic agents and psychosocial interventions.
Psychiatr Prax. 1993 Sep;20(5):193-5.

[“Psychologic marital unfitness” in cyclothymia? A case report on the topic of
the annullment procedure in canon law] [Article in German]

Thiel A, Hilken S.

Psychiatrische Universitatsklinik, Gottingen.

According to the Canon Law (CIC) of the catholic church a marriage can be
annulled because of psychological inability under certain conditions. We present
the case report of a married woman, who fell ill with cyclothymia after her
first childbirth. Her marriage was annulled under canon 1095 (n.3 CIC) because
of psychological inability to fulfill martial obligations. The authors believe
that this represents a clear cut case of discrimination against patients with
mental disorders: on the one hand the catholic church claims that every martial
bond is principally indissoluble; on the other hand they do not eschew
invalidating a marriage due to an affective psychosis. This poses special
problems which are also discussed.
J Nerv Ment Dis. 1993 Aug;181(8):485-93.

A comprehensive review of cyclothymic disorder.

Howland RH, Thase ME.

Department of Psychiatry, Western Psychiatric Institute and Clinic, University
of Pittsburgh School of Medicine, Pennsylvania 15213.

Chronic affective disorders have generated much interest during the past decade
due to increasing recognition of their clinical importance and because of
controversy about their appropriate classification and treatment. The purpose of
this paper was to review cyclothymic disorder. This review will include
historical concepts, clinical phenomenology, family history, biological studies,
and treatment of cyclothymia. In addition, the relationship of cyclothymia to
other psychiatric disorders, such as bipolar, dysthymic, and personality
disorders, is examined. The results suggest that some forms of cyclothymia are
strongly associated with bipolar disorder, but that the condition is clinically
heterogeneous. The problems of existing research in this area and future
directions for research are also discussed.
J Clin Psychiatry. 1993 Jun;54(6):229-34.

Low-dose valproate: a new treatment for cyclothymia, mild rapid cycling
disorders, and premenstrual syndrome.

Jacobsen FM.

Transcultural Mental Health Institute, Washington, DC 20036-6043.

BACKGROUND: Valproate has proved useful in the treatment of manic-depressive and
schizoaffective disorders, usually in daily doses above 500 mg with
corresponding blood levels in the range established for treatment of epilepsy
(50-100 micrograms/mL). Since milder bipolar disorders may be more prevalent
than bipolar I disorder, a prospective study was undertaken to determine whether
lower doses of valproate might be useful for stabilization of mood cycling in
patients having primary diagnoses of cyclothymia or rapid cycling bipolar II
disorder. Additionally, open trials of low-dose valproate were conducted in a
small number of women complaining of premenstrual syndrome. METHOD: Over a
3-year period, outpatients with non-menstrually-related rapid cycling who had
fulfilled DSM-III-R criteria for cyclothymia or bipolar II disorder were started
on open trials of valproate at daily doses of 125 or 250 mg. Doses were adjusted
upward on approximately a monthly basis depending upon clinical response, and
valproate blood levels were obtained. RESULTS: Twenty-six (79%) of 33 patients
(15 cyclothymics, 11 bipolar II) reported sustained partial or complete
stabilization of mood cycling with valproate doses ranging from 125 to 500 mg
(mean = 351.0 mg) corresponding to serum valproate levels (mean = 32.5
micrograms/mL) substantially below the current recommended range. Cyclothymics
required significantly lower doses and blood levels of valproate than patients
with bipolar II disorder for stabilization of mood. Five patients (all bipolar
II) failed to respond fully to low doses of valproate but improved with higher
doses corresponding to blood levels in the 50 to 100 micrograms/mL range. Two
patients had poor responses to valproate or intolerable side effects. In
contrast to bipolar spectrum patients, only three (38%) of eight women with
menstrually related cycling of mood reported good responses to low doses of
valproate, while five reported no response to valproate. CONCLUSION: The
findings suggest that (1) low-dose valproate may be useful in the treatment of
cyclothymia and milder rapid cycling bipolar disorders and (2) there may be a
correlation between the severity of bipolar disorder and the blood level of
valproate required for stabilization such that milder forms of bipolar cycling
require lower doses of valproate.
J Affect Disord. 1992 Oct;26(2):127-40.

Proposed subtypes of bipolar II and related disorders: with hypomanic episodes
(or cyclothymia) and with hyperthymic temperament.

Cassano GB, Akiskal HS, Savino M, Musetti L, Perugi G.

Institute of Clinical Psychiatry, University of Pisa, Italy.

In an attempt to improve the classification of Bipolar II disorders, we have
examined a consecutive series of 687 primary major depressives: 5.1% gave a past
history of mania (Bipolar I), 13.7% met our operational criteria for hypomania
(Bipolar II), and the remaining 81.2% were provisionally categorized as
‘unipolar.’ Although Bipolar II was in some respects intermediate between
Bipolar I and Unipolar, gender, familial bipolar history, age at onset and
course characteristics generally supported its closer kinship to bipolar
illness. Seventy one of the unipolars (10.3% of the total series) further met
our operational criteria for hyperthymic temperament (U-HT), leaving behind a
purer unipolar group of 487 major depressives. With respect to the proportion
having male gender and bipolar family history, U-HT was similar to Bipolar I and
II, and all three differed significantly from pure unipolar; as for age at
onset, number of episodes and related indices of course, BI and BII were
similar, and U-HT was closer to pure unipolar. These findings suggest that major
depressive episodes arising from a hyperthymic temperament (constituting 12.4%
of the ‘unipolar’ universe by conventional definition) are ‘genotypically’
closer to Bipolar II defined by hypomania, and course-wise similar to other
unipolars.
J Clin Psychiatry. 1990 Aug;51(8):335-9.

The prevalence of cyclothymia in borderline personality disorder.

Levitt AJ, Joffe RT, Ennis J, MacDonald C, Kutcher SP.

University of Toronto, Ontario, Canada.

Sixty patients with personality disorders were evaluated by several different
diagnostic instruments to determine the prevalence of cyclothymia in borderline
personality disorder (BPD) and in other personality disorders (OPD). Cyclothymia
occurred more frequently in BPD than in OPD, regardless of which diagnostic
system was used. In contrast, the prevalence of major, minor, and intermittent
depression, hypomania, and bipolar disorder was not significantly different in
BPD as compared with OPD. Cyclothymic borderlines and noncyclothymic borderlines
could not be distinguished on behavioral or functional measures. These results
have implications for the diagnostic validity of both BPD and cyclothymia.
Zh Nevropatol Psikhiatr Im S S Korsakova. 1990;90(3):86-91.

[One of the variants of larvate cyclothymic disorder simulating pathology of the
locomotor system] [Article in Russian]

Lisina MA.

Based on the reported data and the authors’ findings 40 cases of larvate
cyclothymia are described. The pivotal symptomatology of the disease involved
masked hypochondriac subdepressions that imitated pathology of the bones and
joints. In view of this fact the mental disease could not be recognized by the
physicians and was diagnosed erroneously as a pathology of the bones and joints.
The author provides a 3-component structure of the given hypochondriac
depressions and differential diagnostic criteria for their separation from
genuine pathology of the bones and joints.
Am J Psychiatry. 1989 Sep;146(9):1149-54.

Comment in:
Am J Psychiatry. 1990 Jun;147(6):818-9.
Am J Psychiatry. 1991 Aug;148(8):1104-5.

Cyclothymic mood swings in the course of affective disorders and schizophrenia.

Fichtner CG, Grossman LS, Harrow M, Goldberg JF, Klein DN.

Department of Psychiatry, University of Illinois, Chicago.

The authors assessed cyclothymic mood swings and psychosocial adjustment in 38
unipolar depressed, 27 bipolar, 35 schizophrenic, and 27 other psychiatric
patients 4 years after hospital discharge and in 153 normal control subjects.
The patients were significantly more cyclothymic at follow-up than the control
subjects, but there were no differences in cyclothymia between the diagnostic
groups. Cyclothymic patients showed significantly poorer posthospital
functioning than noncyclothymic patients. These findings raise questions
concerning the scope of the hypothesized cyclothymic-bipolar spectrum. Minor
mood swings in a variety of patients with poor posthospital adjustment may
reflect persistent vulnerability to psychopathology.
Acta Psychiatr Scand. 1989 Apr;79(4):363-9.

Personality and personality disorders among patients with major depression in
combination with dysthymic or cyclothymic disorders.

Alnaes R, Torgensen S.

Department of Psychiatry, University of Oslo, Norway.

Personality traits and personality disorders in 298 consecutive outpatients with
pure major depression, major depression with dysthymic or cyclothymic disorder,
pure dysthymic or cyclothymic disorder and other disorders were investigated.
Patients with dysthymic or cyclothymic disorders alone or in combination with
major depression showed more self-doubt, insecurity, sensitivity, compliance,
rigidity and emotional instability. They were more schizoid, schizotypal,
borderline and avoidant according to MCMI and had a higher prevalence of DSM-III
Axis II diagnoses, and more borderline, avoidant, and passive-aggressive
personality disorders, as measured by SIDP. All in all, dramatic and anxious
clusters of personality disorders were more frequent among patients with
dysthymic-cyclothymic disorders in addition to major depression than among
patients with major depression only. The findings elucidated the close
connection between the more chronic affective disorders and the personality
disorders, irrespective of any concomitant diagnosis of major depression.
Psychiatr Neurol Med Psychol (Leipz). 1989 Apr;41(4):230-6.

[Cyclothymia ending in dementia. A case report] [Article in German]

Postrach F.

Nervenklinik, Bezirkskrankenhauses, Friedrich Wolf, Karl-Marx-Stadt.

Three cases of manic-depressive illness are presented which, with various
manifestations of pseudodementia, end in dementia. The relationship of
cyclothymia to dementia is discussed, and the need for diagnosis with the aid of
equipment is stressed. Notwithstanding the absence of systematic theories, it
seems most probable that senile dementia (Alzheimer dementia) may be associated
with cyclothymia.
Acta Psychiatr Scand. 1989 Jan;79(1):11-8.

Characteristics of patients with major depression in combination with dysthymic
or cyclothymic disorders. Childhood and precipitating events.

Alnaes R, Torgersen S.

Department of Psychiatry, University of Oslo, Norway.

The relationship between patients with acute major depression and chronic
affective disorders was investigated in 298 nonpsychotic outpatients. The
patients were categorized into 4 groups: major depression only, major depression
with dysthymic or cyclothymic disorders, dysthymic or cyclothymic disorder
without major depression and one group of other psychiatric disorders. The
patients were interviewed about childhood losses, relationship to parents and
siblings and family atmosphere, their personality characteristics as children,
as well as precipitating events. The reports in the various diagnostic groups
were compared. Patients in the mixed group reported somewhat more traumatic
childhood experiences compared with patients in the pure major depression group
and pure dysthymic-cyclothymic group, and much more traumatic childhood
experiences compared with patients in the group of other disorders.
Precipitating events among patients in the acute major depression group
consisted of more acute external stressors compared with the events of the
patients in the group of chronic affective disorders. Patients with major
depression in combination with pure dysthymic-cyclothymic disorder generally
remembered their childhood as having been more traumatic, with a less satisfying
relationship to their parents.
Zh Nevropatol Psikhiatr Im S S Korsakova. 1989;89(5):76-81.

[Slowly-progressing schizophrenia and cyclothymic disorder with phobic
manifestations in patients under a general practitioner’s care] [Article in Russian]

Vorontsova EA.

A total of 90 patients were investigated in the general practice out-patient
clinics. The patients had not been earlier studied by a psychiatrist and had
unclear forms of endogenous diseases and phobic disorders: 70 patients with slow
progredient schizophrenia, 20 with cyclothymia. Despite the phobic
manifestations of slow progredient schizophrenia and cyclothymia being identical
on the phenomenological level, their structure and time course were different.
Favorable++ and unfavorable clinico-psychopathological prognostic signs were
determined for each of the diseases. The principles of therapeutic and
rehabilitation tactics are discussed with special reference to the patients with
slow progredient schizophrenia and cyclothymia with phobic disorders in primary
health care units. Out-patient group was compared to the patients of dispensary
departments.
Zh Nevropatol Psikhiatr Im S S Korsakova. 1989;89(5):86-91.

[Borderline schizophrenia and cyclothymic disorder associated with disorders of
the menstrual cycle] [Article in Russian]

Anufriev AK, Brutman VI.

Clinico-pathological investigation of borderline schizophrenia (42 women) and
cyclothymia (22 women) with concomitant disorders in menstrual function was
performed in a regional out-patient gynecological department. Major types of the
course of mild psychopathology were identified which involve the endocrine
gynecological dysfunction. Functional disorders of the menstrual cycle are seen
as a class of numerous somatic signs masking the psychopathology in its proper
sense in mental diseases and emerging at the edge of “soft” endogenous mental
disorder. The authors postulate that the central nervous system regions
responsible for child birth are involved into these forms of mental pathology.
The issues of differentiating these ailments involving gynecological dysfunction
from the true endocrine-gynecological pathology are discussed.
Zh Nevropatol Psikhiatr Im S S Korsakova. 1989;89(8):75-80.

[Autonomic vascular asthenia as a component of the psycho- autonomic syndrome in
slowly progressing schizophrenia and cyclothymic disorder in young patients] [Article in Russian]

Kireeva IP.

Investigated were 55 patients with slow-progredient schizophrenia and
cyclothymia aged 17 to 25 with the syndrome of vaso-autonomic dystonia (VAD)
accompanying their mental disorder. VAD was found in 80% of the depressive
cases, hypomaniac syndromes and psychopath-like (residual) states. Each of these
disorders correlated with a distinct type of VAD. In a majority of the cases VAD
manifested after several years of mental disease. The study provides grounds for
combined psychotropic and rational psychotherapy with an early social
rehabilitating assistance. The study substantiated the necessity of psychiatric
services aimed at specialized psychiatric aid to these patients in the general
out-patient clinic network.
Psychiatr Neurol Med Psychol (Leipz). 1988 May;40(5):269-77.

[Effectiveness of bright light therapy in cyclothymic axis syndromes–a
cross-over study in comparison with partial sleep deprivation] [Article in German]

Heim M.

Klinik fur Frauenpsychiatrie, Bezirkskrankenhauses fur Neurologie und
Psychiatrie Arnsdorf bei Dresden.

In a preliminary crossover study, fifty patients with a cyclothymic axial
syndrome were given bright-light treatment, while fifty other such patients were
treated by means of partial sleep deprivation, 60% of the patients responded to
bright-light treatment, as opposed to 50% of the patients partially deprived of
sleep. The superior results of the bright-light treatment (Hamilton Depression
Scale) are confirmed on the Nurses’ Observation Scale for Inpatient Evaluation
and the Profile of Mood States. Comparatively young patients with a not so
extremely marked depression show the best response rates. Bright-light treatment
is also effective against depressive disorders in non-seasonal depressions.
Zh Nevropatol Psikhiatr Im S S Korsakova. 1988;88(6):100-8.

[Cyclothymia of advanced age (based on data from observations at the geriatric
psychiatry office of a general-type polyclinic)] [Article in Russian]

Mikhailova NM, Moroz IB.

Cyclothymia was studied in 129 patients aged over 60 in the gerontology unit of
an outpatient clinic in Moscow. Premanifest period of the disease was analyzed
clinically to single out the functional and somatic disorders. The typology of
the first cyclothymic phases and conditions of their development are described
as related to the ages of the disease manifestation under 60 vs over 60. The
data evidencing the polar nature of the affective disorders are presented to
characterize the natural history of the ailment in senile cyclothymic patients.
Can J Psychiatry. 1987 Nov;32(8):693-4.

Cyclothymic disorder and bromocriptine: predisposing factors for postpartum
mania?

Lake CR, Reid A, Martin C, Chernow B.

Department of Psychiatry, Uniformed Services University of the Health Sciences,
F. Edward Hebert School of Medicine, Bethesda, MD 20814-4799.

Women are most susceptible to psychotic reactions during the postpartum period,
a time of intense psychological and physiological stress. Mania and depression
are particularly common at this time, especially in women with past or family
histories of major or minor affective disorders, specifically cyclothymia and
dysthymia. Close attention after childbirth is warranted to alleviate and
prevent these episodes in such women. Sympathomimetic drugs such as
bromocriptine and the over-the-counter diet aids, which are linked to the
induction of manic episodes, are frequently used in the puerperal period and may
act as catalysts. This case report documents a postpartum manic episode in a
cyclothymic woman who was prescribed bromocriptine, a dopamine agonist, for
prevention of lactation.
Shinrigaku Kenkyu. 1987 Apr;58(1):1-7.

[A study of cyclothymic personality in personality type theory: a structural
interpretation of syntonic and immodithymic personalities in the cyclothymic
personality type] [Article in Japanese]

Wakabayashi A.

This study was undertaken to explore various fundamental characteristics of the
cyclothymic personality type. The subjects were 474 students who were classified
into three basic personality types -cyclothymic, schizothymic and collathymic-
on the basis of their performance on the VERAC Personality Inventory (VPI).
Analyses of two questionnaires (TSPS and Self-Differential) completed by the
subjects indicated that students classified as cyclothymic had a stronger
tendency to recognize their own personality type and to adjust images which
could or might be recognized by others. To explore the cyclothymic personality
in greater detail, this group was classified into two sub-types -hypomanic and
immodithymic types- and two additional tests (EPPS and EFT) were administered to
these subjects. Analysis of the responses to these tests revealed that (a) the
differences between the two sub-types in EPPS coincided to some degree with
earlier reports in the clinical literature, (b) there was no difference between
the sub-types in terms of reaction time or number of errors in EFT, and (c) the
differences obtained between EPPS and EFT were not so clear as those obtained
among the three basic personality types. Overall, these results supported the
contention that cyclothymic personality type is a viable sub-category in
personality type theory.
Arch Gen Psychiatry. 1986 May;43(5):441-5.

Inventory identification of cyclothymia. IX. Validation in offspring of bipolar
I patients.

Klein DN, Depue RA, Slater JF.

We present the ninth in a series of validation studies that support the
effectiveness of the General Behavior Inventory (GBI) in identifying
cyclothymia. This study assessed the potential utility of the GBI in family and
offspring studies by evaluating its ability to satisfy three prerequisites for
use in such research: (1) identification of cyclothymia familially related to
bipolar I disorder, (2) use with young adolescents, and (3) “insensitivity” to
the effects of nonaffective psychopathology and parental nonaffective disorder
in the offspring of control probands. The GBI and a blind, structured diagnostic
interview were administered to 37 offspring of bipolar I patients and 21
offspring of psychiatric control patients, Twenty-seven percent of the offspring
of bipolar patients, but none of the control offspring, were found to have
bipolar forms of affective disorder, primarily cyclothymia (24%). Concordance
between the GBI and interview-derived diagnoses was 95% to 97%, with 98%
specificity and 80% to 90% sensitivity, depending on cutting score location.
Together with the results of previous studies, the findings suggest that the GBI
holds promise for the identification of cyclothymia in several research and
clinical contexts.
Zh Nevropatol Psikhiatr Im S S Korsakova. 1986;86(10):1539-43.

[Characteristics of the course of cyclothymia-like schizophrenia in puberty] [Article in Russian]

Danilova LIu.

Slowly progressive schizophrenia with subclinical affective attacks in
adolescence is characterized by undoubtful differences in the premorbid
characteristics of patients, clinical picture and peculiarities of the course of
the endogenic process. Different variants of the course are related to
structurally and phenomenologically different variants of affective attacks. The
more similar is the course of cyclothymia-like schizophrenia to protracted
non-remission one, the more atypical are affective attacks (adynamic depressions
and nonproductive hypomania); the more paroxysmal is the course, the more marked
and diverse is the clinical picture of depression (dysphoric attacks) and the
more typical are hypomanias. Patients with cyclothymia-like schizophrenia,
besides therapy, are in need of the earliest possible rehabilitative treatment
aimed at the continuation of education under easier conditions which expedites
post-attack readaptation and improves social prognosis.
Psychiatr Neurol Med Psychol (Leipz). 1985 Dec;37(12):718-21.

[Course and form variations of cyclothymic phases in lithium therapy] [Article in German]

Banzhaf M, Bertram W, Schulze F.

The authors have attempted by means of a statistical survey to quantify changes
in the course and, in particular the phase-related and non-phase-related form of
cyclothymic phases during long-term lithium treatment.
Am J Psychiatry. 1985 Feb;142(2):175-81.

The behavioral high-risk paradigm and bipolar affective disorder, VIII: Serum
free cortisol in nonpatient cyclothymic subjects selected by the General
Behavior Inventory.

Depue RA, Kleiman RM, Davis P, Hutchinson M, Krauss SP.

The degree of biologic concordance between bipolar affective disorder and
cyclothymia was assessed within a 3-hour protocol of cortisol functioning.
Cyclothymic subjects, selected by the General Behavior Inventory, showed
cortisol hypersecretion approaching that of subjects with major affective
disorders; they also showed poor modulation of cortisol levels over time, the
degree of which was related to increased current level of depression and to a
chronic, intermittent depressive course. These results not only support the
validity of the General Behavior Inventory but also suggest that cyclothymic
subjects with a chronic depressive course may experience persistent biologic
disturbance similar to that found during episodes of major depression.

PMID: 3970242 [PubMed – indexed for MEDLINE]

 

Psychopathology. 1985;18(2-3):163-6.

Ulcerative colitis: a cyclothymic disorder?

Wiesnagrotzki S, Gathmann P, Kiss A.

While psychogenic aspects in ulcerative colitis have been comprehensively
studied, much less attention has been given to sequence and interaction of
psychic and somatic factors in psychopathological description. Onset of
schizoaffective and cyclothymic symptomatology in 20 ulcerative colitis patients
proved to occur only after somatic manifestation. As later on organic and
psychic relapse never occurred simultaneously, further discussion should be
centered on two points: Does schizoaffective cyclothymic axial syndrome occur
separately from ulcerative colitis manifestation? Or is there a common
etiological, pathogenic base for both somatic and psychic symptoms?
Zh Nevropatol Psikhiatr Im S S Korsakova. 1985;85(10):1521-6.

[Psychopathologic features of cyclothymic-like depressive states in
slowly-progressive schizophrenia in pre-puberty and puberty] [Article in Russian]

Danilova LIu.

One hundred and thirty depressive states of the cyclothymic level have been
analyzed in 51 patients (24 boys and 27 girls) or prepuberal and puberal age who
suffered from slowly progressive schizophrenia. Five types of the depressive
syndrome have been specified, namely simple, anxiety-like, dysphoric, adynamic
and asthenic. An atypical nature of these types due both to the form of the
disease course and age-specificity is shown.
Eur Arch Psychiatry Neurol Sci. 1984;234(4):250-7.

[Social integration and contacts to reference persons of the normal social
environment in inpatient treatment in the psychiatric hospital. A prospective
catamnestic study of patients admitted for the first time with schizophrenic and
cyclothymic psychoses] [Article in German]

Bocker FM.

Fifty first-admission inpatients (27 women, 23 men; mean age 35.1 years) with
schizophrenia (n = 35) or affective disorders (n = 15) participated in a
standardized, half-open interview about contact with people outside the
hospital. The frequency of contact was compared with outcome, as based on a
1-year follow-up. Nearly all patients (48 of 50) had “direct” contact with
relatives and friends during the week (means = 3/week): 45 patients had
visitors, 13 went home on weekends. Thirty-five patients had contact with the
outside by telephone, and 21 by letter; only 12 patients indicated no “indirect”
contact. The frequency of contact had no relationship to sex, age or diagnosis.
The significant factors were: structure of the patient’s family, his/her
educational and occupational level, social network, means of admission,
conditions of hospitalization, and length of stay. The distance between the
patient’s residence and the hospital markedly influenced the frequency of visits
and weekend holidays. The importance of frequent interaction with the usual
social environment was verified by follow-up: 11 patients with rare or only
average contact had unfavorable results (readmission or suicide by 1 year after
discharge or long-term hospitalization); on the other hand, none of the patients
with frequent direct contact outside the hospital showed poor results. There is
no reason for indiscriminate criticism of the relatives of psychiatric
inpatients according to etiological hypotheses of “family research”; above all,
patients without relationships with a family or friends have to be regarded as
at risk.(ABSTRACT TRUNCATED AT 250 WORDS)
Ann Med Psychol (Paris). 1983 Jul-Aug;141(7):721-30.

[Delusional thematic alternation and cyclothymia] [Article in French]

Sizaret P, Degiovanni A, Chevrollier JP, Gaillard P.

The authors discuss the case of a 36 year old woman who, for several years, has
been delirious and who has shown signs of an affective disorder, alternatively
suffering from hypomanic and depressive episodes. What is most interesting is
that she expresses erotomaniac delusions while she is elated and persecutory
delusions while she is depressed. The authors propose an psychopathological
explanation for her disorder.
Zh Nevropatol Psikhiatr Im S S Korsakova. 1982 Sep;82(9):73-9.

[Chronic hypomania as a stage of acquired cyclothymia] [Article in Russian]

Moroz IB, Nefed’ev OP.

The authors examined 28 patients with chronic hypomanic states that form within
the bounds of acquired cyclothymia after a schizophrenic psychosis. Two types of
the chronic hypomanias were differentiated. The first was hyperthymia, a
residual pseudopsychotic state characterized with a combination of cycloid and
schizoid features with an invariably elated mood. The patients were energetic,
purposeful, indefatigable, and industrious at work. No signs of disease progress
were observed for a long time. The second type was subpsychotic hypomania
associated with a slow, but still continuing progress of the disease. The elated
mood was combined with marked signs of the defect (emotional and intellectual
impoverishment, psychopathy-like changes) and still persisting positive
symptoms. The activity and ability to adapt themselves enabled these patients to
remain sufficiently compensated socially at the new, lower level of the
adaptation. Later the psychopathological disorders got deeper, and their scope
increased.
Am J Psychiatry. 1982 Jun;139(6):747-52.

Lithium prophylaxis of depression in unipolar, bipolar II, and cyclothymic
patients.

Peselow ED, Dunner DL, Fieve RR, Lautin A.

The authors assessed lithium’s prophylactic effect against depression in
unipolar (N = 43), bipolar II (N = 102), and cyclothymic (N = 69) patients using
a longitudinal life-table analysis and calculated the probability of remaining
free of a depressive episode. The probability of remaining free of one
depressive episode after 2 years of taking lithium ranged from 42% to 55% for
the bipolar II patients, 31% to 42% for the unipolar patients, and 26% to 36%
for the cyclothymic patients. The average probability of suffering one
depressive episode severe enough to require either pharmacologic intervention or
hospitalization in a 2-year period was 51% for the bipolar II patients, 64% for
the unipolar patients, and 69% for the cyclothymic patients.
Psychiatr Neurol Med Psychol (Leipz). 1981 Aug;33(8):449-57.

[Kurt Schneider’s concept of cyclothymic mania in the light of a
research-oriented catatonic syndrome] [Article in German]

Koehler K, Jacoby C, Guth W.

Catatonic motor signs were specifically sought out in the case records of 89
episodes of Schneider-oriented mania. Only some so-called “minor” catatonic
motor phenomena were found and “major” catatonic motor disturbances, recently
reported to frequently occur in some American samples of mania, were completely
absent. Indeed, the only motor abnormalities seen in Schneider-oriented mania
appeared to be of a kind and degree typically associated with Kraepelins
“hypomania”. These findings are then primarily discussed in historical
perspective and their relationships to some important modern research trends
also highlighted.
Biol Psychiatry. 1979 Aug;14(4):581-6.

A longitudinal CNV study in a group of five bipolar cyclothymic patients.

Rizzo PA, Amabile G, Caporali M, Pierelli F, Spadaro M, Zanasi M, Morocutti C.

The authors carried out a longitudinal study in five subjects with bipolar
cyclothymic psychosis, recording contingent negative variations in the same
patients in the different phases of illness and under normal clinical
conditions. An average voltage decrease was found in the depressive phases and a
more conspicuous decrease in the manic phases. Furthermore, an evident
postimperative negative variation was present in four subjects during the manic
phase. The authors set forth tentative psychological and neurophysiological
interpretation of their results.
Psychiatr Clin (Basel). 1978;11(3):132-8.

[Cyclothymia and the brain stem. The question of symptomatic cyclothymia on the
basis of observations in insufficiency of the basilar arterial system] [Article in German]

Marneros A, Philipp M.

Seven patients with an insufficiency in the basilar arterial system showed a
typical endogenous depression. We assumed that the temporal coincidence of
neurological and psychial syndromes was not accidental but both were caused by a
circulation disturbance in the cerebral stem structures.
Am J Psychiatry. 1977 Nov;134(11):1227-33.

Cyclothymic disorder: validating criteria for inclusion in the bipolar affective
group.

Akiskal HS, Djenderedjian AM, Rosenthal RH, Khani MK.

The authors identified 46 cyclothymic probands from a random pool of 500
psychiatric outpatients and prospectively followed them over a 2-3 year period.
They used 50 bipolar patients with a definite history of mania and 50 patients
with personality disorders as control groups. Although 66% of the cyclothymic
outpatients had previously received the diagnosis of hysteria or sociopathy,
their pedigrees were similar to those seen in classical bipolar manic-depressive
illness; furthermore, 44% of the cyclothymic group experienced brief hypomanic
episodes while taking tricyclic drugs, and 35% developed full-blown hypomanic,
manic, or depressive episodes during drug-free follow-up. The authors conclude
that these findings provide evidence for a cyclothymic-bipolar spectrum.
Pharmakopsychiatr Neuropsychopharmakol. 1976 Sep;9(5):247-56.

[Comparison of evaluation scales and performance tests for measuring the
severity of cyclothymic depressions.] [Article in German]

Lehrl S, Straub R, Straub B.

Usually the severeness of cyclothymical depression is assessed by self-or
arbiter’s evaluation scales. These assessments are influenced by – mainly verbal
– disturbing variables that hitherto may hardly be controlled. Measurements of
performance provide less falsified results. However, they are influenced by the
premorbid level of general intelligence and by the age of the patient. These
disturbing variables, however, can be controlled rather well. Empirical
investigations show that the assessment of the severeness of cyclothymical
depression measured by performance tests of evaluation scales leads to different
results. Nevertheless, both types of tests are valid for measuring depressions.
Therefore, both are to be taken into account for assessment of severeness.
Psychiatr Neurol Med Psychol (Leipz). 1976 Aug;28(8):500-8.

[Cyclothymic depression and performance. Comparison of the efficiency of
agitated and non-agitated cyclothymic depression patients on a brief test of
severe depression] [Article in German]

Straub R, Straub B, Lehrl S.

Agitated and non-agitated cyclothym depressive patients were compared relative
to their results in a short achievement test for measuring degree of depression;
the agitated patients worked significantly less slowly in two of the five
subtests. These differences may exist premorbidly and can be explained by a
theoretical concept of arousal. We propose to control the subject’s activational
states which — besides the control of age and intelligence — might possibly
precise the test results relative to the depth of depression.
Hautarzt. 1976 Feb;27(2):74-5.

[Correlation between bipolar cyclothymia and psoriasis vulgaris. A case report] [Article in German]

Foerster K.

Report of a case with cyclothymia and psoriasis. During the depression periods,
the psoriasis got worse and during the manic periods the skin lesions improved
even without any dermatological therapy.
Fortschr Neurol Psychiatr Grenzgeb. 1975 Aug;43(8):381-440.

[Chronobiological aspects of cyclothymia (author’s transl)] [Article in German]

Papousek M.

The paradoxical effect of sleep deprivation in endogenous depression has renewed
the traditional interests of psychiatrists in the rhythmic phenomena associated
with the symptomatology and course of cyclothymia. During the last decade, the
rapid development of clinical research on sleep, neuroendocrinology,
chromobiology and chronopathology in conjunction with important developments of
methodology and statistical procedures have enabled a modern reconceptualization
of the relationship between cyclothymia and disturbances in biological rhythms.
An intensive review of the literature on circadian, ultradian, and infradian
rhythms is reported here, and their relationship to the course and individual
phases of cyclothymia is explored. The results of traditional analyses of sleep
stages which had originally indicated that particular disturbances of sleep may
be specific to cyclothymia have been shown to be incorrect. Rather, the
abbreviation and fragmentation of sleep and the decrease of del asleep with
concomitant increase in shallow stages have been found as well in serious sleep
disturbances of other origins. Striking inter-and intra-individual variabilities
in REM-sleep parameters characterize not only psychotic depression and severe
mania but also a wide range of other acute psychoses…

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