Bipolar disorders cyclothymia

Manic-depressive illness connotes a psychotic disorder of affect that occurs episodically without external cause. In endogenous depression (melancholia), mood is persistently low. Mania refers to the opposite condition (p. 234). Patients may oscillate between these two extremes with interludes of normal mood. Depending on the type of disorder, mood swings may alternate between the two directions (bipolar depression, cyclothymia) or occur in only one direction (unipolar depression). 

It appears that a number of complications await the recovering bipolar patient after an episode of mania. For example, Lucas et al. ( 44) reported on a retrospective linear discriminant analysis of 100 manic episodes (1981 to 1985) during the recovery phase and found that the incidence of subsequent depression was 30% in the first month. Many episodes were transient, however, and did not necessarily require treatment. This phenomenon could be successfully predicted in 81% of cases in which there is a premorbid history of cyclothymia with either a personal or a family history of depression. The highly significant association between family history and postmanic depression again supports the hypothesis of a genetic basis for bipolar disorder. 

Affective illness is a recurrent illness characterized by episodes of depression -and in some cases, mania - that recur and remit repeatedly during the course of a patient s life. A group of minor conditions characterized by chronic intermittent symptomatology such as dysthymia or cyclothymia also exists. Sleep research over the past decades has primarily focused on major affective disorders such as unipolar or bipolar disorders, and minor affective conditions have been neglected in the research literature. Accordingly, the present chapter will largely rely on publication in that field. 

This is a chronic disorder, with approximately one-third of individuals later developing a major affective disorder (Akiskal et al., cited by Hirschfeld and Goodwin 1988). Cyclothymia is so strikingly consistent with bipolar disorder with regard to symptoms, family history, course, and treatment response, that some clinicians argue for its categorization as a variant of bipolar disorder. 

Family studies support a high risk-factor association for first-degree relatives with bipolar disorder. Additionally, other conditions are highly represented in relatives of bipolar individuals, including bipolar II, major depression, cyclothymia, schizoaffective disorder, and suicide. 

Recommended baseline and routine laboratory tests for valproate are listed in Table 68-12. Data from clinical trials in acutely manic patients indicated that there was an earlier response when trough serum levels were greater than 45 mcg/mL during the Hrst week of treatment. Although therapeutic serum concentrations of valproic acid have not been established in bipolar disorder, most clinicians use the anticonvulsant therapeutic range of 50 to 125 mcg/mL taken 12 hours after the last dose. Patients with cyclothymia or mild bipolar II disorder may have a therapeutic response to lower doses and blood levels, whereas some patients with a more severe form of bipolar disorder may require up to 150 mcg/mL. Serum valproic acid levels are usually determined every 1 to 2 weeks during the first 2 months, and then every 3 to 6 months during maintenance therapy. ... 

According to the DSM-IV, clients with a diagnosis of cyclothymic disorder have milder experiences than those who suffer from bipolar disorders although the symptoms are more consistent and last for approximately two years. In order to be diagnosed with cyclothymic disorder, the client s history must indicate that he or she has not been without hypomanic and depressive symptoms for a period of two months (American Psychiatric Association, 1994) a client with a major depressive episode only should not be diagnosed as cyclothymia. 

Bipolar disorders A group of mental disorders historically referred to as manic depression or bipolar affective disorder, characterized by extreme fluctuations in mood. There are three major diagnoses that fall in this area, bipolar I, bipolar II, and cyclothymia. 

Bipolar Syndromes. There are three distinct bipolar syndromes described in DSM-IV BRAD I, BRAD II, and cyclothymic disorder. The most severe subtype, BRAD I, is comprised of episodes of mania and/or depression. BRAD II, in contrast, is defined by episodes of hypomania and/or depression. BRAD II is arguably the most difficult to distinguish from the mood instability of patients with Cluster B personality disorders. Cyclothymic patients fluctuate between phases of hypomania and those of mild depression reminiscent of dysthymia. Although the symptoms of cyclothymia produce significant morbidity and impairment, the disability falls far... 

Predictors of a positive response with valproate include rapid cycling, mixed episodes, comorbid panic disorder, organic mental disorders (e.g., head trauma), and mental retardation. " Low-dose valproate (125 to 500 mg/day) has been reported to be effective in reducing mood cycling in bipolar II disorder and cyclothymia. Oral loading with divalproex sodium, 20 mg/kg per day, may produce a rapid reduction in manic and psychotic symptoms within 4 days without causing major side effects, although there may be a lag time to obtain full antimanic efficacy. Development of tolerance and loss of efficacy with valproate occurs in some patients after several years of treatment." ... 

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