A Sudden Shift in Moods

With Cyclothymia, a Milder Form Of Bipolar Disorder,
Life's Little Ups and Downs Can Loom Large

By Stacey Colino

Like most teenagers, Andrew Solomon was often at the mercy of his moods -- but in his case this situation persisted into his thirties.

"During my up periods, I'm lucid and articulate," said Solomon, author of the partly autobiographical "The Noonday Demon: An Atlas of Depression," which won the National Book Award for nonfiction in 2001. "I have clarity and can see patterns in my work, and I can write loads of publishable material in one night. I'm also very affectionate with people I care about."

But when his moods would turn, as they invariably did, he could withdraw or have angry outbursts.

Once, after an annoying phone call, he slammed down the phone so hard it broke. Another time, when an acquaintance who frequently drank too much showed up at his home tipsy and immediately poured herself a cocktail, Solomon "smashed the glass and yelled at her that she had to leave immediately," he recalls. After such explosions, he would "spend the next week apologizing."

Yet it wasn't until three years ago that Solomon, now 42, learned there is a word for the mood swings that have affected him since his youth: cyclothymia.

Cyclothymic disorder, as it is sometimes known, is a milder cousin of bipolar disorder. Like bipolar disorder, cyclothymia has high and low phases, though the highs are not as high and the lows not as low. It can be crippling nonetheless. And it is a risk factor for bipolar disease itself, with up to 50 percent of those with cyclothymia eventually developing bipolar disorder. Major depression is also a higher risk.

The hypomanic, or upbeat, phase features symptoms such as elevated mood, increased self-esteem, decreased need for sleep, racing thoughts, an increase in goal-directed activity and excessive involvement in pleasurable activities.

These symptoms might last for four or more days, then alternate with periods of mildly depressive symptoms such as sadness, pessimism, fatigue, feeling guilty, trouble concentrating and changes in sleep or appetite. For a person to be diagnosed with the disorder, this alternation persists for at least two years.

The American Psychiatric Association estimates that 2.2 million U.S. adults have cyclothymia, about half as many as those with bipolar disorder. But as bipolar disorders have gained visibility in the clinical community and popular culture, cyclothymia is being identified and treated more often.

"There's been a general increase in awareness of bipolarity as prominent people have come out with books about it," said Fred Goodwin, professor of psychiatry at the George Washington University Medical Center and the author of "Manic-Depressive Illness." Bipolar conditions have also gained clinical prominence thanks to the introduction two years ago of Lamictal (lamotrigine), an anticonvulsant drug that has been proven to delay the mood swings, especially the depressive ones, associated with bipolar disorder.

"It's called 'therapeutic optimism,' " Goodwin explains. Once a treatment is proven effective for an illness, there is "high motivation to look for people who have it. With a drug like Lamictal . . . there's further motivation to evaluate whether someone is just moody or whether this is something that could be helped with pharmacology." Carol C. Kleinman, an assistant clinical professor of psychiatry at the George Washington and a psychiatrist in private practice in Chevy Chase, estimates that 60 percent of people with cyclothymia respond to an anticonvulsant agent.

Less Lethal

While cyclothymia's mood changes can be abrupt and unpredictable, they are not as severe as in the more serious forms of the disease, which are known as Bipolar I and Bipolar II. The main difference between cyclothymia and Bipolar I is in the severity of mania, and the difference between cyclothymia and bipolar II in the severity of depressive symptoms.

But the milder condition can still be disabling and disorienting. "People who have more or less continuous mood fluctuations, as people with cyclothymia do, can end up with more limitations in life than people with major disorders," Goodwin said. "Because they don't know how they're going to feel from day to day, they don't have a firm footing in relationships or in their work. And they lack the ability to have confidence in what a mood means, whether it's a signal about a relationship or a work situation or a spontaneous change."

The German psychiatrist Ewald Hecker introduced the concept of cyclothymia in 1877, but its definition has evolved from a mild problem with mood to its current status, in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), as a mood disorder alongside bipolar disorder and major depression. Cyclothymic disorder also appears in the International Classification of Diseases (ICD-10), published by the World Health Organization.

Yet the condition has traditionally been overlooked by those who have it and the doctors who've treated them. This may be because there's a fine line between pathological and normal mood fluctuations.

"The threshold is when a person is really having trouble in their relationships or at work or in school," said Kleinman. "Often, he added, "it's a friend or family member who says, 'I think there's a problem here.' "

Complicating matters, people usually seek professional help when they're feeling down, not up. " . . . They come in because they're depressed or hurting," Goodwin said. "They don't come in saying, 'Doctor, I'm hypersexual or too creative.' We'd all love to have that." People who come in during a down period of cyclothymia may be misdiagnosed with -- and mistreated for -- unipolar depression.

In therapy, there's also a mood-driven memory bias: When people are depressed, they tend to remember their past depressions, not their periods of euphoria or super-productivity, according to Goodwin. So what they report can give a mental health professional a skewed picture of what's really been going on with them.

Cycles of Vulnerability

The cause of cyclothymic disorder, which usually begins in the teens or twenties, is unknown, but there appears to be a genetic component. People who have a family history of bipolar disorder are particularly susceptible. In a recent study involving healthy, symptom-free volunteers, researchers in France found that a cyclothymic temperament clusters in families with affective disorders, particularly in those with a legacy of bipolar disorders or depressive disorders.

There's also likely an environmental influence, since stress, personal loss, drug or alcohol use, or even insufficient sleep can trigger episodes or mood fluctuations. In people with cyclothymia, "the brain has less capacity to buffer itself against what's happening in the environment," Goodwin explains.

Linda Sexton was diagnosed with cyclothymia in 1983, when her children were toddlers. A daughter of the poet Anne Sexton, who suffered from severe depression and committed suicide when Linda was 21, Linda began to have mood swings when she struggled with disciplining her children.

"When I found myself replicating the spanking I had experienced as a child and promised I wouldn't do, I went into therapy," said Sexton, who lives in the San Francisco Bay area. "I was having periods of depression during which I was unable to complete tasks and didn't feel like I had anything to offer my children, which was killing me because I considered them the most precious thing in my life." Then she'd have surges of hypomanic behavior -- for instance, going out and buying 10 pairs of shoes at a time.

Gradually, her cyclothymia got worse, especially when she was treated with antidepressants. She had free-floating anxiety and surges of self-hatred. Her marriage fell apart. In 1996, Sexton was diagnosed with a full-blown bipolar disorder.

At this point, diagnosing cyclothymia isn't an exact science.

"It's kind of a cookbook diagnosis that's based on a standard number of criteria the patient meets," explains Dave M. Davis, a clinical psychiatrist and medical director of the Piedmont Psychiatric Clinic in Atlanta.

Currently, mental health professionals rely on a clinical evaluation, DSM-IV checklists and an accurate history of the person's moods and behavior. A relative of the patient can often help with compiling such a history, Goodwin said, because he can make connections between a person's behavior and negative consequences or recall a pattern of behavior.

"I had a lawyer once who had come in because he was feeling depressed," Goodwin recalls. "He didn't see himself as hypomanic, but he was so irritable that his kids didn't want to come home and eat with him. His wife reminded him it was the same summer that he bought three cars and called all of his bosses [expletive]s and got fired. Then he turned to his wife and said, 'Is this what the doctor meant by hypomania?' He just hadn't put two and two together."

Back on an Even Keel

"There isn't much point in treating cyclothymia without mood stabilizers," Goodwin said. "This is not something over which [people] can exert total voluntary control."

While drugs like lithium and depakote have been the treatment of choice for both bipolar and cyclothymic disorders in the past, they often carry unpleasant side effects such as weight gain and sluggishness.

In 2003, a breakthrough came with the FDA's approval of Lamictal for the long-term treatment of bipolar disorders. "It's very effective on the depressive side and mildly effective on the high side," Goodwin said. "With it, these people can begin to trust their emotions again."

What doesn't help are antidepressants taken by themselves, as Jennifer Richards discovered after being misdiagnosed with depression more than 10 years ago.

"The antidepressants I was given made my moods worse," recalled Richards, a receptionist in Boston. "I'd feel invincible and drive 100 miles an hour or max out my credit cards. Or I'd become very angry, loud and obnoxious; I hadn't experienced outbursts like that before. Friends stopped talking to me, and I was fired from two jobs."

It wasn't until she began treatment with a new psychotherapist that she was diagnosed with cyclothymia and put on a mood stabilizer. After that, she said, "I wasn't afraid of myself anymore."

Not only can antidepressants throw someone with cyclothymia into mania, they can boost the risk of having the disorder evolve into full-blown bipolar, Goodwin said. "It happens up to one-third of the time. Antidepressants should only be used with a mood stabilizer, and they should not be used indefinitely."

The trouble is, people are often reluctant to take a mood stabilizer when they're on a high swing.

"When you're hypomanic and you feel euphoric and on top of the world, who wants to take a medication that will take that away?" said Prentiss Price, a psychologist at the Counseling and Career Development Center of the Georgia Southern University in Statesboro and author of "The Cyclothymia Workbook." "But the higher the mood gets, the more at risk you are for problems with judgment or risky behavior."

Of course, therapy is also important. "They need to relearn who they are and get off their addiction to their highs," Goodwin said. "It's like cocaine addicts: They feel like they need that high to be interesting, appealing, sexually attractive or fun people."

Thanks to medication and psychotherapy, Andrew Solomon's moods are now under control: He still has up days and down days, but he spends more time on an even keel.

"Now I usually have reactive swings," he said. "When something happens, I might have an exaggerated response to it. But my moods have become more logical and rational and less extreme. They're easier for me and for other people to live with."

Resources

For more information about mood disorders:

Families for Depression Awareness ( http://www.familyaware.org/ ), offers help in recognizing and dealing with depressive and mood disorders.

Depression and Bipolar Support Alliance ( http://www.dbsalliance.org/ ), offers confidential screening for bipolar disorder, depression and anxiety, plus information and referrals to support groups.

Stacey Colino is a Washington area freelance writer. Comments: health@washpost.com.

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