What is it called when a person experiences a period of euphoria elevated self esteem increased talkativeness and a decreased need for sleep?

Cyclothymic disorder

Cyclothymic disorder, also known as cyclothymia, involves numerous periods of depression as well as hypomania. The symptoms are not severe enough to be a major depressive or hypomanic episode. Symptoms must last for more than 1 year in children and more than 2 years in adults.

Cyclothymia

Cyclothymia is characterized by recurrent subthreshold episodes of hypomania and mild to moderate depression alternating over at least 2years (1year in children). These mood switches often emerge during adolescence and typically occur rapidly and unpredictably, leading to significant instability and psychological distress (Akiskal, 2001; Brieger & Marneros, 1998). Clinical observations suggest that sleep disturbances frequently occur in conjunction with cyclothymia (Akiskal, Khani, & Scott-Strauss, 1979). A large-scale web-based survey indicated that “cyclothymic temperament” has been associated with prolonged sleep latency, later sleep schedule, frequent nighttime awakenings, poor sleep quality, and high rates of daily and occasional use of sleep medications (Ottoni, Lorenzi, & Lara, 2011). Recently, sleep disturbances have also been found to be worse in young persons with cyclothymia compared to clinical controls and generally similar, albeit slightly lower, to those with bipolar disorder (Van Meter, Youngstrom, Youngstrom, Feeny, & Findling, 2011).

Although it has been proposed that the core pathophysiology of cyclothymia is closely related to internal desynchrony among biological rhythms (Papousek, 1975), limited empirical data is currently available. A recent case study of a middle-age cyclothymic female noted a combination of higher “energetic mood” toward the end of the day and sleep duration of about 3hours (Totterdell & Kellett, 2008). In many cases, cyclothymia is also subject to seasonal changes, with more prominent depressive episodes during winter (Akiskal, 2001).

Because of its more subtle symptoms, cyclothymia may go undetected or misrepresented in clinical settings. Nevertheless, recent epidemiological findings estimate that approximately 40% of the population with a history of major depressive disorder also reports experiencing subthreshold mania symptoms at some stage of their life (Angst et al., 2010). Thus, researchers may have to reach beyond formal clinical settings when investigating the interplay between sleep or circadian rhythms and low-severity mania.

Other persistent mood disorders

Cyclothymia is a condition in which there is a persistent instability of mood, involving numerous periods of mild depression and mild elation that fall short of meeting diagnostic criteria for depressive and manic episodes. It usually develops in early adult life and tends to run a chronic course. Cyclothymia is more common among relatives of people with bipolar affective disorder and some affected individuals will go on to develop bipolar disorder.

Some people experience chronic depressive symptoms of a severity that falls short of diagnostic criteria for depressive episodes. This condition is known as dysthymia and onset is typically during adolescence or early adulthood. When the onset is later in life, the disorder often occurs in the aftermath of a depressive episode, usually associated with bereavement or other obvious stress. Depressive episodes sometimes occur in the course of dysthymia and the combination of dysthymia and recurrent depressive disorder is sometimes referred to as ‘double depression’.

7 Cyclothymic Disorder

The issue of cyclothymia as a disorder versus a personality or Axis II problem is also one that requires more research (Howland and Thase 1993). Indeed, it is difficult to find research on cyclothymic disorder, as patients with this rather stable condition rarely present for treatment. Patients diagnosed as cyclothymic experienced brief hypomanic periods (lasting fewer than four days) and brief mild depressive periods (lasting fewer than two weeks). Within a day, mood alterations from feeling high to feeling low are common. This mood pattern is persistent for two years or more.

Personality

There is a great deal of support for the proposition that cyclothymia (which can be defined as a lifelong pattern of subsyndromal fluctuations between mild depression and mild mania) probably represents a forme fruste of classical bipolar disorder (Akiskal and Pinto, 1999). Up to a third of cyclothymic individuals will develop an episode of hypomania or mania at some point in their lives. Similarly, the personality traits of sociotropy (high need for approval) and neuroticism (excessive reactivity to stress) have been strongly associated with both major depression and bipolar disorder, and current evidence suggests that at least part of the genetic risk for mood disorders takes the form of inheritance of these “depressogenic” character traits and cognitive styles.

Body Image in Bipolar Disorder

The BDs include bipolar I disorder, bipolar II disorder, cyclothymia, and BD not otherwise specified. The discussion here will focus on bipolar I disorder, which has a worldwide prevalence of 3–5%. The essential feature of bipolar I disorder is a clinical course that includes the occurrence of one or more manic episodes or mixed episodes. According to the DSM-IV-TR, a manic episode is defined as a distinct period of abnormally or persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). Some of the criteria for a manic episode listed in the DSM-IV-TR may include body image aberrations such as inflated self-esteem or hypersexual behavior. For a mixed episode, criteria for a manic episode and for a major depressive episode (except duration) are met nearly every day for at least 1 week. BD most often starts with depression (75% of the time for women, 67% for men). Most patients experience both depressive and manic episodes, although 10–20% experience only manic episodes.

In mania or hypomania (manic symptoms that are clinically significant but insufficient to cause social/occupational impairment), patients may display an enhanced or inflated sense of body image, such that one may feel especially attractive or sexual. As unstable mood is an integral part of BD, patients may have fluctuating perceptions of their body image. Generally, it seems that the higher the degree of fluctuation in self-esteem, the worse the prognosis in patients with BD. One study measured self-esteem daily over a 1-week period and found that BD patients had more fluctuations in self-esteem compared to MDD patients and controls. Similarly, studies have found that cyclothymic temperament, which entails continuous shifts in mood and perception as well as variations in self-esteem, is more severe in BD patients than in MDD patients or controls. Unstable self-esteem, in combination with unrealistic standards of success, may predispose individuals with BD toward extreme shifts in self-evaluation, which may include appraisal of one’s physical attributes (i.e., body image).

Low self-esteem is believed to be a risk factor contributing to the onset of BD in genetically vulnerable individuals. An early manifestation of low self-esteem in BD was indicated by a study in which adolescents with BD were found to have lower self-esteem than adolescent controls. This may be related to the relatively high incidence of childhood traumas (e.g., sexual or physical abuse) reported by BD patients (one study found more than a 50% incidence of traumatic events in youth with diagnosed BD). Another explanation, which is referred to as the complication or scar hypothesis, is that low self-esteem is a consequence of BD. As widely documented, many BD patients experience a number of impairments due to the illness, such as cognitive deficits and occupational and social difficulties, which may contribute to the development and maintenance of low self-esteem.

Living with BD may also disrupt identity formation. BD patients often have difficulty in establishing a coherent identity due to their changing and contrasting mood episodes. Conversely, disruption of identity formation may worsen the experience of BD. That is, an unstable self-image may cause unpredictable behaviors and interpersonal conflicts. These negative experiences in turn may damage self-esteem and darken perceptions of one’s self and body image. Thus, the relationship may be cyclical. BD may also give rise to low self-esteem through the negative stigma attached to the illness. One study found that awareness of stigmatization was correlated with lower self-esteem in remitted BD patients.

A multimodal theory explains BD as a specific dysregulation of the behavioral activation system (BAS), a system involved in behavioral and neurological responses to cues signaling opportunities to achieve or lose rewards. According to the expanded version of this theory, high and low BAS activation can lead to mania and depression, respectively, depending on the type of eliciting events and how they are appraised in terms of relevance and efficacy. Research points to a specific BAS-related cognitive style in BD characterized by performance evaluation, autonomy, self-criticism, and an emphasis on goal attainment. This can manifest in some BD patients as a futile (and frustrating) quest for physical and cosmetic perfection (skin, weight, etc.). Since low self-esteem seems to fit thematically into such a cognitive style, it may be part of the cognitive manifestation of BAS dysregulation and may underlie a cognitive deficit in how patients feel about their bodies. Indeed, the above explanations of low self-esteem as implicated in the onset, clinical manifestation, and subsyndromal symptomatology of BD may all be accounted for by a more fundamental vulnerability such as BAS dysregulation.

Differential diagnoses

Both depressive and manic disorders include schizophrenic illnesses and organic brain syndromes as possible differential diagnoses. The differential diagnosis of depressive disorders is considered elsewhere in this volume, and the following account highlights the important conditions from which manic disorders must be distinguished.

The differential diagnosis of manic disorders (Box 21.3) includes:

Cyclothymia

Schizophrenia

Organic brain syndromes

Illicit substance misuse

Iatrogenic causes.

Conditions Characterized by Extremes of Mood Lability

(See Nelson Textbook of Pediatrics, p. 157.)

The bipolar disorders include bipolar I disorder, bipolar II disorder, and cyclothymic disorder. All are characterized by the presence of either mania or hypomania. Mania manifests acutely, leads to significant functional impairments, and is characterized by racing thoughts, distractibility, delusions of grandeur, and other disturbances in thinking. Problematic behaviors during a manic episode include recklessness (e.g., excessive participation in social activities, high-risk sexual activity, buying sprees), agitation, decreased sleep, and excessive talkativeness. A manic episode is defined as an abnormally elevated, euphoric, expansive, or irritable mood for at least 1 week unless treated. This mood disturbance is associated with at least 3 of the following symptoms or 4 if the mood is irritable:

Grandiosity

Decreased need for sleep

Talkativeness

Racing thoughts

Distractibility

Excessive goal-directed activity or psychomotor agitation

Reckless pursuit of pleasure

The symptoms of a hypomanic episode are the same, though are present for a shorter duration (i.e., 4 days or fewer), are not associated with psychotic symptoms of delusions or hallucination, and are not severe enough to cause major social or academic dysfunction. Up to 10% of patients with hypomania will eventually develop mania.

Bipolar I disorder is characterized by the presence of manic episodes. Patients may also have prior or subsequent episodes of hypomania or major depression, though these are not required. Bipolar II disorder is characterized by the presence of major depression episodes and hypomania. Cyclothymic disorder is a chronic, cyclic illness of hypomania and depressive symptoms without episodes of major depression.

Comorbid psychiatric conditions include eating disorders, ADHD, conduct disorders, panic disorders, social phobias, adjustment disorders, substance use disorders, and substance-induced disorders. The lifetime prevalence of bipolar I disorder is as high as 1.6%, and that of bipolar II disorder is 0.5%. Approximately 15% of adolescents with recurrent major depression eventually develop bipolar illnesses.

The differential diagnosis of the bipolar disorders includes schizophrenia and medical conditions that cause changes in mental status, particularly thyroid disorders, Cushing disease, and multiple sclerosis (see Table 27.3). Substance-induced mood disorders must also be considered, particularly those associated with cocaine, tricyclic antidepressants and selective serotonin reuptake inhibitors. The clinician should obtain a detailed family history as bipolar disorder frequently runs in families. Because the condition is often undiagnosed in parents, the questions should be directed toward the presence of the symptoms for bipolar disorders. The following principles should guide the evaluation of patients with symptoms of depression or mania:

Recognize the symptoms mania and hypomania.

Remember that depressed patients often have bipolar disorders.

Obtain a thorough family history to look for symptoms of mood disorders.

Consider bipolar illnesses in patients with any disruptive disorder that does not respond to treatment.

Assess for drug and/or alcohol use as substances may induce bipolar disorder, and substance use is frequently a comorbid condition.

Borderline personality disorder is a chronic personality disorder characterized by intense mood lability, impulsivity, identity disturbances, and unstable relationships. The diagnosis may be challenging in adolescents whose appropriate psychologic development includes the forging of identity and personality traits; however, since borderline personality disorder is associated with significant morbidity and potential mortality, it should be considered in the differential diagnosis of a patient presenting with significant mood or behavioral issues. Diagnosis requires 5 or more of the following:

Significant efforts to avoid real or imagined abandonment

Unstable and intense relationships with extremes of idolization and devaluation

Marked identity disturbances with unstable sense of self

Significant impulsivity in at least 2 areas that are potentially self-damaging: spending, sexual activity, substance abuse, reckless driving, or binge eating

Recurrent suicidal or self-mutilating behavior

Intense dysphoria, irritability, or anxiety

Chronic feelings of emptiness

Inappropriate anger

Transient, stress-related paranoia or dissociation

Both genetic and psychosocial factors are believed to be causative. Risk factors for borderline personality disorder include a history of abuse, neglect, or early parental loss. The median population prevalence is approximately 6% in primary care settings and is as high as 10% in outpatient mental health clinics. Females are more frequently diagnosed than males, at a ratio of 3 : 1.

Mood Disorders

The DSM-IV mood disorders include major depressive disorder, bipolar disorder, cyclothymic disorder, and dysthymic disorder. Sleep disturbances are highly prevalent in mood disorder patients and sleep-related symptoms are incorporated into the DSM-IV diagnostic criteria of these disorders. The major depressive episode diagnostic feature options include insomnia or hypersomnia nearly every day, while for a manic episode they include decreased need for sleep. Insomnia complaints commonly include the full spectrum of difficulty initiating and maintaining sleep with reported frequent awakenings and trouble returning to sleep. There may be a description of light or unrefreshing sleep. Patients may also complain of nightmares. While the sleep disturbances are most common during illness exacerbations, mood disorder patients often experience insomnia predating and persisting after episodes of depression or mania. Longitudinal studies suggest that insomnia often begins prior to other depressive symptoms and that insomnia is a robust predictor of recurrence in people with previous depressive episodes. Abundant epidemiologic evidence shows that a history of insomnia or persistent insomnia increases the risk of the future development of major depressive disorder.

The investigation of PSG and related EEG signal analyses during sleep has represented a major research focus into the biology of the regulation of sleep and mood and the pathophysiology of major depression. Although specific sleep abnormalities are not present in all patients experiencing major depressive episodes, there is a strong tendency that there may exist a disturbance in sleep continuity, decreased percentage and total amount of slow-wave sleep, and particular abnormalities in REM sleep. While decreased sleep continuity and slow-wave sleep may be associated with numerous conditions, the REM sleep changes in major depression are relatively specific. The objectively measured sleep continuity disturbances reflect the subjective insomnia complaints. The REM sleep abnormalities include a shortening of the initial REM latency and a prolonged duration of the first REM episode. There may be an increase in the total amount of REM sleep, as well as an increase in the overall REM activity (number of eye movements) and the density of eye movements during REM sleep. These REM sleep changes tend to correlate with the severity of the depression. Spectral analysis studies have demonstrated consistent changes in slow-wave activity in depressed subjects with a decrease in the ratio of δ-wave activity in the first non-REM (NREM) episode relative to the second NREM episode. This δ-sleep ratio also tends to correlate with a patient's clinical state. Objective measurements of sleep features during manic or depressive episodes in bipolar disorder patients have been limited but generally have had results similar to those with major depressive patients. The EEG signal abnormalities observed in mood-disordered patients do not necessarily normalize with the resolution of depressive or manic episodes. It has been speculated that these features may represent trait characteristics of individuals with greater vulnerability to mood disorders.

Sleep loss may have significant clinical effects on patients with mood disorders. Full night or strategically timed partial sleep deprivation can result in acute temporary improvements in mood and related symptoms in depressed patients. In contrast, sleep deprivation in bipolar disorder patients can have a deleterious effect in precipitating manic episodes. The maintenance of a regular schedule and healthy sleep habits may have important preventive effects in promoting mood stability.

Patients evaluated for mood disorders should be assessed for possible sleep difficulties and patients reporting insomnia or hypersomnia should be examined for possible mood disorders. Both cognitive/behavioral and pharmacologic treatments for mood-disordered patients should result in improved sleep as the psychiatric symptoms resolve, although several psychotropic medications can cause insomnia. Additional strategies that independently target the sleep disruption may improve sleep as well as mood symptoms. Selected patients, especially those reporting seasonal affective disorder symptoms, may benefit from therapeutic bright light exposure.

Depression

A common symptom of depressive disorders, including major depressive disorder and bipolar disorder or cyclothymia is disruption of sleep. Sleep may be characterized as either significant insomnia, with problems initiating and maintaining sleep, or, conversely, hypersomnia, with excessive sleep. Most commonly, patients with depression experience difficulty maintaining sleep, with early wakening and difficulty falling back asleep. Alternatively, patients may also have difficulty maintaining sleep in the middle of the night (middle insomnia). It is also common for individuals with major depressive disorder to experience hypersomnia (complaints of EDS). Rather than exhibiting clear problems in maintaining alertness, patients with major depression often complain of feeling tired/fatigued and frequently exhibit apathy. Patients with major depression often also complain of concentration and memory problems. Chronic insomnia may weaken the capacity to cope with life stressors, further exacerbating depressive symptoms.