Cyclothymia, the Quintessential Mood Temperament: Ignored or Forgotten? Part II: Children and Adolescents

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Van meter and Youngstrom succinctly summarize the state of the field¹:

“Cyclothymic disorder is a chronic and impairing subtype of bipolar disorder, largely neglected in pediatric research. Consequently, it is rarely diagnosed clinically, despite potentially being the most prevalent form of bipolar spectrum presentation. In children with depression, cyclothymic temperament has been associated with a higher risk of bipolar disorder and may be helpful in the prediction of future bipolarity among youth presenting with depressed mood. This could be particularly important because the treatment guidelines for unipolar depression and bipolar depression are not the same.”

In children, cyclothymia will manifest as wide fluctuations between externalizing and internalizing behaviors and moods with many subsyndromal depressive, mixed, and manic symptoms. These symptoms frequently get subsumed under the broadly defined DSM terms of major depressive disorder (MDD), attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and the most recent disruptive mood dysregulation disorder (DMDD).

According to Rovai, et al, “Extremes of emotionality and behaviors occurred preponderantly in children who showed cyclothymic traits. In particular, cyclothymic subjects have reported the highest rates of anxiety/sleep disorders and sensitivity to separation, in addition to eating disorders in females and antisocial-aggressive behavior in males… These data support the idea that the cyclothymic disposition is the most ‘morbid’ temperament,” as it is associated both with internalizing and externalizing disorders.²

Hantouche and Perugi stated that, “An appropriate approach to treat cyclothymia is needed to reduce controversy surrounding the overdiagnosis of the bipolar spectrum and pediatric bipolar disorder. In fact, this approach combining subthreshold presentations of bipolarity (typical and atypical ups and downs) and affective temperaments, represents a clear and precise approach for complex clinical syndromes with depression, psychic excitement, anxiety, impulse control, substance use, attention deficit, and personality disorders”³ (Table 1¹).

Table 1. Diagnostic Validators of Course and Genetics to Help Child and Adolescent Psychiatrists Recognize and Treat Youth With Cyclothymic Disorder¹

Van Meter, et al, also present a developmental course perspective⁴:

“Our study suggests that clearly operationalized criteria for cyclothymic disorder can be applied to identify a distinct category of youth with symptoms and impairment similar to other youth with bipolar spectrum disorders and different from non-bipolar diagnoses. Importantly, our results also indicate that the cyclothymic phenotype may be associated with developmentally limited presentations of bipolar disorder, as many of the youth experienced symptom remission over the 2-year follow-up.”

In concluding, the authors state that using the research diagnostic criteria for cyclothymic disorder based on DSM-5 criteria “could reduce misdiagnosis and increase our understanding of this prevalent, but largely ignored, diagnosis.”

Cyclothymia as a Neurodevelopmental Disorder

According to our Italian and French colleagues⁵:

“The emotional dysregulation of cyclothymic type should be considered a neurodevelopmental disorder. This hypothesis is empirically strengthened by the observation that such an emotional dysregulation is met more frequently than expected in a wide span of neurodevelopmental disorders including ADHDDDHD, autism spectrum disorders, Tourette syndrome and intellectual disability. As a consequence, cyclothymic disposition should be understood in a developmental perspective as a result of very complex interactions between constitution and environment… Cyclothymia is associated with early onset of bipolar disorder in childhood or adolescence and with extreme spontaneous or medication-induced mood cyclicity and instability. Finally, emotional dysregulation associated with cyclothymic temperament and other neurodevelopmental disorders seems to represent the most common substrate of the high comorbidity rates with anxiety, impulse control, and also with alcohol and substance use disorders frequently observed in bipolar samples and in patients with neurodevelopmental disorders.”

A developmental perspective on cyclothymic-hypersensitive temperament (CHT)is discussed in Table 2⁶.

Table 2. A Developmental Perspective on Cyclothymic-Hypersensitive Temperament⁶

Akiskal explains that, “According to some authorities, 1 pathway to juvenile bipolar disorder is childhood hyperactivity. This is not to say that childhood hyperactivity is an obligatory precursor of bipolar disorder—nor that all cases of ADHD are bipolar—but to suggest that up to a third of juvenile onsets of bipolar disorder give history of some form of ‘hyperactivity’ prior to the more overt bipolar manifestations.”⁷

Further, “Using the Cyclothymic-Hypersensitive Temperament Questionnaire (child and adolescent version), several studies show that in children and adolescents a CHT at baseline significantly predicted the bipolar and particularly bipolar II, outcome during a 2- 4-year follow-up of juvenile inpatients with an index diagnosis of MDD episode.”⁸

Given the studies indicating the presence of cyclothymia as early as age 6 years, Geller reports that, “There is mounting evidence that recurrent early-onset mood disorders, once considered as developmental and transient symptoms, are in fact severe and life-threatening bipolar disorders.”⁹

These studies represent a small sampling of research in pediatric cyclothymia over the past quarter-century that should take precedence over newer formulations of disruptive mood disorder not supported by many experts or the classic diagnostic validators of course, family history/genetics, symptoms, or response to treatment and biomarkers.

Van Meter and Youngstrom cautioned in 2012: “The proposed addition of DMDD to the DSM-V could potentially lead to confusion with regard to cyclothymic disorder. DMDD and its predecessors, severe mood dysregulation disorder and temper dysregulation disorder with dysphoria, are based on limited data and have significant symptom overlap with other childhood disorders.” They conclude¹:

“Specifically, irritable mood with temper outbursts is the primary criterion for DMDD and irritable mood can be the primary symptom of mania seen in cyclothymic disorder. Furthermore, both diagnoses require a duration of 1 year. Although DMDD has exclusion criteria that preclude the presence of other symptoms of mania, in the case of cyclothymic disorder, full criteria for mania are never met, making a differential diagnosis challenging. Adult studies show that cyclothymic disorder is a prevalent and impairing disorder. Further obscuring it in child research seems unwise. Research needs to examine the boundaries between DMDD versus cyclothymic disorder and other childhood disorders.”

Suicide Risk

According to Innamorati, et al¹⁰:

“Our study indicates that prevalence of MDD patients with the cyclothymic temperament may be as high as 39% in samples of inpatients with unipolar depression, while among bipolar patients around 1 out of 2 patients may have the cyclothymic phenotype. Patients with the cyclothymic phenotype differ from their pairs: they report higher hopelessness and suicidality than patients with pure major mood disorders…The fact that patients with unipolar depression and cyclothymic temperament report higher hopelessness should be considered a sign that these patients are at higher risk for suicide, since research consistently indicated hopelessness as a potent proximal risk factor for suicidal intent, and current suicidal ideation.”

Several studies indicate that that cyclothymic temperament is significantly overrepresented among suicide attempters.^11,12

Part III of this series will address the differentiation between cyclothymia and borderline personality disorder, as well as treatment and concluding thoughts.

Dr Yost provides psychiatric consultations through telemedicine in Tucson, Arizona.

References

1. Van Meter AR, Youngstrom EA. Cyclothymic disorder in youth: why is it overlooked, what do we know and where is the field headed? Neuropsychiatry (London). 2012;2(6):509-519.

2. Rovai L, Maremmani AG, Rugani F, et al. Do Akiskal & Mallya's affective temperaments belong to the domain of pathology or to that of normality? Eur Rev Med Pharmacol Sci. 2013;17(15):2065-2079.

3. Hantouche E, Perugi G. Should cyclothymia be considered as a specific and distinct bipolar disorder? Neuropsychiatry. 2012;2(5):407-414.

4. Van Meter AR, Youngstrom EA, Birmaher B, et al. Longitudinal course and characteristics of cyclothymic disorder in youth. J Affect Disord. 2017;215:314-322.

5. Perugi G, Hantouche E, Vannucchi G. Diagnosis and treatment of cyclothymia: the “primacy” of temperament. Curr Neuropharmacol. 2017;15(3):372-379.

6. Kochman FJ, Hantouche EG, Ferrari P, et al. Cyclothymic temperament as a prospective predictor of bipolarity and suicidality in children and adolescents with major depressive disorder. J Affect Disord. 2005;85(1-2):181-189.

7. Akiskal HS. The emergence of the bipolar spectrum: validation along clinical-epidemiologic and familial-genetic lines. Psychopharmacol Bull. 2007;40(4):99-115.

8. Rihmer Z, Akiskal KK, Rihmer A, Akiskal HS. Current research on affective temperaments. Curr Opin Psychiatry. 2010;23(1):12-18.

9. Geller B, Luby J. Child and adolescent bipolar disorder: a review of the past 10 years [published correction appears in J Am Child Adolesc Psychiatry 1997 Nov;36(11):1642]. J Am Acad Child Adolesc Psychiatry. 1997;36(9):1168-1176.

10. Innamorati M, Rihmer Z, Akiskal H, et al. Cyclothymic temperament rather than polarity is associated with hopelessness and suicidality in hospitalized patients with mood disorders. J Affect Disord. 2015;170:161-165.

11. Pompili M, Rihmer Z, Akiskal HS, et al. Temperament and personality dimensions in suicidal and nonsuicidal psychiatric inpatients. Psychopathology. 2008;41(5):313-321.

12. Rihmer A, Rozsa S, Rihmer Z, et al. Affective temperaments, as measured by TEMPS-A, among nonviolent suicide attempters. J Affect Disord. 2009;116(1-2):18-22.