4.5.9 Dysthymia, Cyclothymia, and Hyperthymia: Hagop S. Akiskal

New Oxford Textbook of Psychiatry (2 edn)
Michael Gelder (ed.) et al.
https://doi.org/10.1093/med/9780199696758.001.0001
Published: 2012 Online ISBN: 9780191743221 Print ISBN: 9780199696758
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4.5.9 Dysthymia, cyclothymia, and hyperthymia 
Hagop S. Akiskal
https://doi.org/10.1093/med/9780199696758.003.0091 Pages 681–692

Published: February 2012
Abstract
Long before psychiatry moved to the outpatient arena in the latter part of the twentieth century,
psychiatrists had observed milder mood disturbances among the kin of patients hospitalized for
endogenous or psychotic depressions or mania. Some were described as sullen, morose, or otherwise
moody, without discrete episodes; others reported self-limited episodes, but often went untreated.
With the advent of modern treatments, practitioners are being increasingly consulted by patients
presenting with attenuated a ective disturbances. Although the relationship of these ambulatory
mood states and more classical severe a ective disorders has not been resolved, there is emerging
sleep electroencephalography (EEG) and familial-genetic evidence that a continuum exists between
them. Along the same lines, studies conducted in the United States and Germany into what were once
described as ‘neurotic’ depressions have revealed a progression to more endogenous, psychotic, or
bipolar switching. For these and related reasons, current o cial classi cation systems such as the
ICD-10 and DSM-IV, have dropped the neurotic-endogenous dichotomy. Sceptics would perhaps argue
that the new categorization of depressive disorders into dysthymic and major subtypes is not much of
an improvement. Nonetheless, the new terminology has drawn attention to a large universe of human
su ering that had been neglected in the past, and the conceptualization of dysthymia as a variant of
mood disorder has had a far-reaching impact on diagnostic and therapeutic habits of clinicians
worldwide. The emerging concept of the bipolar spectrum, which does include manic, cyclic depressive
(bipolar II), cyclothymic, hyperthymic and related conditions, is beginning to have a similar impact on
practice. The subthreshold mood disorders are not only in continuum with more pathological mood
states, but they also provide a bridge with normal a ective conditions. In this context, temperament,
as a construct encompassing a ective personalities, is currently enjoying a renaissance as one of the
possible substrates for the origin of mood disorders. Temperament classically refers to an adaptive
mixture of traits which, in the extreme, can lead to illness or modify the expression of superimposed
a ective states. The subthreshold conditions covered in this chapter represent the extreme
expressions of these temperaments. A new self- administered instrument, the TEMPS-A, now
validated in 10 language versions, is being used internationally to measure the classical constructs of
depressive, cyclothymic, hyperthymic, and irritable, as well as anxious temperaments.
Subject: Psychiatry, Neurology, Addiction Medicine, Medical Ethics, Public Health and Epidemiology,
Immunology, Clinical Genetics, Public Health, Radiology, Psychotherapy, Medical Statistics and
Methodology
Series: Oxford Textbooks in Psychiatry
Collection: Oxford Medicine Online
Subthreshold a ective conditions, personality, and temperament
Long before psychiatry moved to the outpatient arena in the latter part of the twentieth century,

psychiatrists had observed milder mood disturbances among the kin of patients hospitalized for
endogenous or psychotic depressions or mania. Some were described as sullen, morose, or otherwise
moody, without discrete episodes; others reported self-limited episodes, but often went untreated. With the
advent of modern treatments, practitioners are being increasingly consulted by patients presenting with
attenuated a ective disturbances. Although the relationship of these ambulatory mood states and more
classical severe a ective disorders has not been resolved, there is emerging sleep electroencephalography
(1–3)
(EEG) and familial-genetic evidence that a continuum exists between them. Along the same lines,
(4,5)
studies conducted in the United States and Germany into what were once described as ‘neurotic’
depressions have revealed a progression to more endogenous, psychotic, or bipolar switching. For these and
related reasons, current o cial classi cation systems such as the ICD-10 and DSM-IV, have dropped the
neurotic-endogenous dichotomy. Sceptics would perhaps argue that the new categorization of depressive
disorders into dysthymic and major subtypes is not much of an improvement. Nonetheless, the new
terminology has drawn attention to a large universe of human su ering that had been neglected in the past,
and the conceptualization of dysthymia as a variant of mood disorder has had a far-reaching impact on
(6)
diagnostic and therapeutic habits of clinicians worldwide. The emerging concept of the bipolar spectrum,
which does include manic, cyclic depressive (bipolar II), cyclothymic, hyperthymic and related conditions,
(7)
is beginning to have a similar impact on practice.
The subthreshold mood disorders are not only in continuum with more pathological mood states, but they
also provide a bridge with normal a ective conditions. In this context, temperament, as a construct
encompassing a ective personalities, is currently enjoying a renaissance as one of the possible substrates
for the origin of mood disorders. Temperament classically refers to an adaptive mixture of traits which, in
the extreme, can lead to illness or modify the expression of superimposed a ective states. The subthreshold
conditions covered in this chapter represent the extreme expressions of these temperaments. A new self-
(8)
administered instrument, the TEMPS-A, now validated in 10 language versions, is being used
internationally to measure the classical constructs of depressive, cyclothymic, hyperthymic, and irritable,
as well as anxious temperaments.
In the current literature, various terms such as ‘minor a ective states’, ‘intermittent depression’,
(9)
‘hysteroid dysphoria’, and ‘atypical depression’ are often used for subthreshold disorders. These terms
are avoided here, because in contemporary practice these conditions are at least as ‘typical’ as major mood
disorders: their impact on the su erer is not time-limited, nor minor, and involves more than a state of
(10)
demoralization and moral foible. The following passage from Sir Aubrey Lewis is à propos:
…Severe emotional upsets ordinarily tend to subside, but mild emotional states … tend to persist,
as it were, autonomously. Hence the paradox that a gross blatant psychosis may do less damage in
the long run than some meager neurotic incubus: a dramatic attack of mania or melancholia, with
delusions, wasting, hallucinations, wild excitement may have far less e ect on the course of man's
life than some deceptively mild a ective illness which goes on so long that it becomes inveterate.
The former comes as a catastrophe and when it has passed the patient takes up his life again …
while with the latter he may never get rid of his burden.
It is a curious fact that most subthreshold a ective conditions, while symptomatologically attenuated, tend
to pursue a chronic course. This raises the question, partially addressed in this chapter, whether these
conditions in their trait expressions might serve some useful function, even as they burden the individual
with cares and instability which could predispose to full-blown a ective disease. By their very chronicity,
these suba ective conditions pose di cult conceptual and clinical questions about their di erentiation
(11)
from personality disorders. Sceptics might argue that subthreshold a ective conditions are nothing more
than personality disorders and/or expressions of ‘neuroticism’. Actually, a close examination of the Eysenck
personality inventory, which ranges over a large terrain of depressiveness, anxiousness, emotionality, and
(12)
mood lability among others, reveals low-grade intermittent a ective symptomatology. And at least one

genetic investigation has reported that neuroticism and major depression in women share substantial
(13)
genetic underpinnings. Nonetheless, clinicians have always preferred categorical constructs, because
neuroticism and related personality constructs do not do justice to the rich clinical phenomenology of
disorders within the suba ective realm. I nally wish to point out that terms like ‘neurotic’, ‘psychopathic’,
or ‘personality disorder’ used as epithets to describe a person have pejorative connotations. They tend to
describe what is negative about someone, whereas ‘temperament’ refers to the optimum mixture of both
liabilities and assets regarding a human being, thereby rendering therapeutic work possible with relatively
little countertransference. This is particularly relevant when we consider the distinct possibility that the
(11)
many dysthymic and cyclothymic individuals might otherwise be labeled ‘borderline.’
The dysthymic spectrum
History
The term ‘dysthymia’ (meaning ‘bad mood’) originated in classical Greek and is still in current use in that
country with the same connotation. In the Hippocratic School, it was considered as part of the broader
concept of melancholia (meaning ‘black bile’). A temperament predisposed to melancholia was also
delineated, and referred to individuals who were lethargic, brooding, and insecure. It was not until the early
nineteenth century that dysthymia was reintroduced into medicine by the German physicians, Stark and
(14)
Fleming to describe depressions in inpatients that pursued a chronic course. Eventually, dysthymia came
to subsume all mood disorders. The major residue of dysthymia in the latter sense in Europe today is the
French rubric of les dysthymies, as a synonym for troubles de l'humeur; the DSM-IV or ICD-10 ‘dysthymic
disorder’ in that country is translated as le trouble dysthymique.
The more direct lineage of our current usage of the term dysthymia is to be found in the latter part of the
nineteenth century in the work of Kraepelin, who delineated the depressive disposition as one of the
constitutional foundations of a ective episodes. The condition often began early in life, such that by
adolescence many showed an increased sensitivity to life's sorrows and disappointments: they were
tormented by guilt, had little con dence in their abilities, and su ered from low energy. As they grew into
adulthood, they experienced ‘life with its activity [as] a burden which they habitually [bore] with dutiful
self-denial without being compensated by the pleasures of existence’. In some, these temperamental
peculiarities were so marked that they could be considered ‘morbid without the appearance of more severe,
delimited attacks…’ (clearly foreshadowing the modern concept of trait dysthymia). In other cases,
recurrent melancholia arose from this substrate without de nite boundaries (again anticipating the concept
of ‘double-depression’).
Subsequently, Kurt Schneider in his opus Psychopathic Personalities devoted considerable space to a
depressive type whose entire existence was entrenched in su ering. Building on this rich phenomenological
(15)
tradition, our research in Memphis helped in operationalizing the core characteristics of such patients
encountered in contemporary practice: gloomy, sombre, and incapable of having fun; brooding, self-
critical, and guilt-prone; lack of con dence, low self-esteem, preoccupation with failure; pessimistic, easily
discouraged; easy to tire, sluggish, and bound to routine; non-assertive, self-denying, and devoted; shy and
(16)
sensitive. These traits have excellent internal consistency and discriminatory ability. Similar concepts
(17)
have also appeared in the Japanese literature, with particular emphasis on self-critical attitudes,
persistence in work habits, and devotion to others. Finally, the French construct of la depression
(18)
constitutionelle has emphasized the lethargic aspects with a sense of inadequacy. A self-rated scale in all
(8)
of these languages now can assist in reliable and valid assessment of depressive temperament traits.
The classical tenet in psychiatry has been that a ectively ill patients recover from their acute episodes with

relatively little symptomatic residua and dysfunction. Community psychiatry, which has given renewed
visibility to the temperamentally expressed low-grade uctuating depressive disorders, has challenged this
classic view. With the advent of DSM-III, such patients are now o cially designated as ‘dysthymic.’ In the
ICD-10 classi cation, the low-grade depressive baseline is considered the main pathology; only an
occasional superimposed depressive episode is permitted, provided that it is mild. In DSM-IV, at least two
patterns have been described: pure dysthymia uncomplicated by major depression and a more prevalent
pattern of dysthymia complicated by major depressive episodes that could be even moderate or severe in
intensity (and which has been dubbed ‘double depression’).
The mystery of this incapacitating depressive subtype—long recognized, but only recently sanctioned in
o cial diagnostic manuals—is that, in their habitual condition, su erers lack the classical ‘objective’ or
‘major’ signs of acute clinical depression, such as profound changes in psychomotor and vegetative
functions. Instead, patients consult their doctors for more uctuating complaints consisting of gloominess,
lethargy, self-doubt, and lack of joie de vivre; they typically work hard, but do not enjoy their work; if
married, they are deadlocked in bitter and unhappy marriages which lead neither to reconciliation nor
separation; for them, their entire existence is a burden: they are satis ed with nothing, complain of
everything, and brood about the uselessness of existence. As a result, in the past those who could a ord it
were condemned to the couch for what often proved to be interminable analysis. The legitimization of
dysthymia as a clinically signi cant variant of a ective disorder in both the United States and WHO
classi cations has helped the cause of more cost-e ective treatments.
To sum up, for nearly 2500 years physicians have described individuals with a low-grade chronic depressive
pro le marked by gloominess, pessimism, low enjoyment of life, relatively low drive, yet endowed with
(19)
self-critical attitudes and su ering for others. This constellation is as much a virtue as it is a disposition
to melancholy, and many dysthymic patients presenting clinically have various admixtures of major
depression. This is compatible with a spectrum-concept of depressive illness, which de nes various degrees
of severity.
Clinical picture and diagnostic considerations(20)*

Diagnostic criteria for dysthymia in both DSM-IV and ICD-10 stipulate a two-year duration of low-grade
depressive symptoms, exclusive of such indicators of severity as suicidality and psychomotor disturbances.
Dysthymia is distinguished from chronic major depressive disorder by the fact that it is not a sequel to well-
de ned major depressive episodes. Instead, patients often complain that they have always been depressed.
Most are of early onset (less than 20 years). A late-onset subtype rst manifesting after the age of 50 is
much less prevalent and has not been well characterized clinically, but it has been identi ed largely through
studies in the community.
At their best, dysthymic individuals invest whatever energy they have in work, leaving none for leisure or
social activities. According to Tellenbach, such dedication to work represents overcompensation against
depressive disorganization. Kretschmer had earlier suggested that such persons were the ‘backbone of
society,’ devoting their lives to jobs that require dependability and great attention to detail. These features
represent the obsessoid facet of dysthymia. Such individuals may seek outpatient counseling and
psychotherapy for what some clinicians might consider ‘existential depression’: individuals who complain
that their life lacks lustre, joy, and meaning. Others present clinically because of an intensi cation of their
gloom to the level of clinical depression; history of lifelong low-grade depressive symptoms would
distinguish them from episodic major depressive patients.
The proverbial dysthymic patient will often complain of having been ‘depressed since birth’. In the eloquent
words of Kurt Schneider, “they view themselves as belonging to an ‘aristocracy of su ering”. These

hyperbolic descriptions of su ering in the absence of more objective signs of depression earn such patients
the label of ‘characterological depression’. The description is further reinforced by the uctuating
depressive picture that merges imperceptibly with the patient's habitual self, leading to the customary
clinical uncertainty as to whether dysthymic disorder belongs to the a ective or personality disorder
domains.
At their worst, patients with low-grade depression having an intermittent course can present such
instability in their life, including suicidal crises, that some clinicians would entertain the diagnosis of
borderline personality disorder. This is not consistent with the classic picture of dysthymia arising from a
temperamental type with more mature ego structure described above. Depressives with unstable (that is to
say, ‘borderline’) personality structure more often belong to the irritable cyclothymic–bipolar II spectrum.
The greatest overlap of dysthymia is with major depressive disorder, but di ers from it in that symptoms
tend to outnumber signs (more subjective than objective depression). Thus, marked disturbances in
appetite and libido are uncharacteristic, and psychomotor agitation or retardation is not observed.
Nonetheless, subtle ‘endogenous’ features are not uncommonly reported: inertia, lethargy, and anhedonia
that are characteristically worse in the morning. Because many patients with dysthymia presenting
clinically uctuate in and out of a major depression, the core DSM-IV criteria for dysthymia tend to
emphasize vegetative dysfunction, whereas the alternative criterion B for dysthymia in a DSM-IV appendix
lists cognitive symptoms; although the latter appear more characteristic of trait dysthymia, the DSM-IV
eld trial could not demonstrate their speci city for dysthymia.
A Milan-San Diego collaboration of a large sample from community and primary-care medical settings
revealed that negative mood (by de nition), along with low energy, poor concentration, low self-esteem,
sleep and appetite disturbance, and hopelessness (in descending order) were the most common symptoms
of dysthymia. These data suggest that the cognitive and somatic symptoms are not easily separable in
practice. None the less, this study did raise the possibility that factors could be discerned along two di erent
axes: ‘negative a ectivity’ and ‘lassitude with poor concentration’. In our experience, patients loading on
the latter factor often complain of hypersomnia and may exhibit subtle bipolar signs; alternatively, they
might have some link to the poorly de ned constructs of neurasthenia, chronic fatigue syndrome, and
bromyalgia. In terms of di erential diagnosis, patients with chronic fatigue syndrome present with
disabling fatigue and, typically, deny depressive symptoms; patients with bromyalgia complain of pain; by
contrast, the typical patient with dysthymia cannot stop relating to the physician his or her litany of
depressive symptoms. Polysomnography, though not yet de nitive, may shed some light on di erentiating
bromyalgia from dysthymia proper.
Although dysthymic disorder represents a more restricted concept than does its parent, neurotic
depression, it is still quite heterogeneous. Anxiety is not a necessary part of its clinical picture, yet
dysthymia is sometimes diagnosed in patients with anxiety and neurotic disorders. That clinical situation is
perhaps to be regarded
as a secondary or ‘anxious dysthymia’ or, as some British authors seem to prefer, as part of a ‘general
neurotic syndrome’ (an implicit partial return to the now defunct concept of neurotic depression).
The clinical picture of dysthymic disorder that emerges from the foregoing descriptions is quite varied, with
many who uctuate in and out of major depression, whereas in others the pathology is woven into the
habitual self. Prospective follow-up supports a continuum between temperament, dysthymia and major
depression. These considerations suggest that a clinically satisfactory operationalization of dysthymia must
include both symptoms and trait characteristics (Table 4.5.9.1). The following vignette illustrates this more
prototypical form of dysthymic su ering.

Table 4.5.9.1 The core characteristics of dysthymia
Long-standing subthreshold depression of a fluctuating or persistent nature
Gloomy and joyless disposition
Brooding about the past and guilt prone
Low drive and lethargy
Low self-esteem and preoccupation with failure
Identifies su ering as part of the habitual self
(19)
Summarized from Akiskal.
Case Study: This 37-year-old never-married male teacher presented with the complaint that he was ‘tired
of living’ and was considering ‘ending it all’. He said that much of his life had been ‘wasted’, he had never
known any joy, and that all human existence for him was a ‘tragic mistake of God’. He was known to be a
dedicated and talented teacher, but he felt all his e orts had been ‘useless and in vain’. He said he probably
was ‘born depressed’, because he had not known any happiness and that the only utility he could have for
mankind was ‘to serve as a specimen to be researched—to shed light on human misery’. Although he
conceded that some women found him interesting, even intellectually stimulating, he said he could not
enjoy physical intimacy, that even orgasm lacked passion; nonetheless, he masturbated frequently,
fantasizing about married female teachers—only to feel guilty. We could not document any major a ective
episodes. He stated that he had always functioned at a ‘mediocre level’ (which was at variance with the good
feedback students had given him year after year); but did admit he ‘appreciated work, because there was
nothing else to do’. He denied alcohol and drug habits. There had never been any periods of hypomania, but
one of his maternal aunts had been treated for a ‘cyclical depression’ and was apparently doing well on
lithium. The patient's mother was a sombre serious work-oriented woman who had raised three children
and had done voluntary work for the church, but had no depressive complaints. His father had died from a
coronary attack, but his side of the family was otherwise unremarkable.
Although both DSM-IV and ICD-10 omit suicidal preoccupations in their diagnostic criteria for dysthymia,
as testi ed by the above case, this is what often brings patients to clinical attention.
Course(20)
An insidious onset of depression dating back to late childhood or the teens, preceding any superimposed
major depressive episodes by years, even decades, is the most typical developmental background of
dysthymic disorder. A return to the low-grade depres-sive pattern is the rule following recovery from
superimposed major depressive episodes, if any, hence the designation ‘double depression’.
Few studies have studied the phenomenology of dysthymia in childhood. DSM-IV does not seem to
distinguish between childhood and adult dysthymia, yet current clinical experience indicates that the main

symptoms in childhood dysthymia include irritability, low self esteem, fatigue, low mood, guilt, poor
concentration, anhedonia, and hopelessness; as in adults, comorbid anxiety disorders were prevalent;
suicidality was more common in adolescents. These ndings should be useful in dysthymic children in
future studies. A long-term prospective Pittsburgh study of prepubertal children has revealed an episodic
course of dysthymia with remissions and exacerbations, and eventual complication by major depressive
episodes, as well as hypomanic, manic, or mixed episodes postpubertally. Persons with dysthymic disorder
presenting clinically as adults tend to pursue a chronic ‘unipolar’ course, which may or may not be
complicated by major depression: they rarely develop spontaneous hypomania or mania. However, when
treated with antidepressants, some adult patients with dysthymia may experience brief hypomanic switches
that typically disappear when the antidepressant dose is decreased. Although ICD-10 and DSM-IV would not
‘allow’ the occurrence of such switches in dysthymia, systematic clinical observation have veri ed their
occurrence in between 10 and 30 per cent of dysthymic patients. In that special dysthymic subgroup, the
family histories are typically positive for bipolar disorder. Such patients, often conforming to the double
depressive pattern, represent a clinical bridge between major depressive disorder and bipolar II.
A 12-year NIMH prospective study has shown that patients with major depressive disorder spent 44 per cent
of their course in low-grade depression (versus 15 per cent of time in major depressive episodes). This
suggests that major depression, dysthymia, or otherwise subsyndromal depression constitute somewhat
arti cial conventions on the threshold and duration of depressive illness, representing alternative
manifestations of the same diathesis. In this context, residual intermorbid depressive symptoms have been
con rmed as being strongly predictive of a rapid relapse into a new major depressive episode. Various
‘major’ and ‘minor’ depressive conditions described in DSM-IV and its appendix must not be viewed as
distinct depressive subtypes, but part of a symptomatic continuum. Fig. 4.5.9.1 shows a diagram of these
putative relationships within a broad depressive spectrum.
Fig. 4.5.9.1

Diagram to show putative relationships within a broad depressive spectrum.
Epidemiology(20)
From 1966 to 1980, Index Medicus listed no more than 10 articles on chronic depressions. Since 1980, when
dysthymia was rst introduced in DSM-III, at least 500 articles have appeared on chronic depression,
mostly on dysthymia. This phenomenal growth in research interest parallels the increasing public health
signi cance of this disorder. It is estimated that 3–5 per cent of the world population is su ering from
dysthymia. Like major depressive disorders, dysthymia is twice as common in women as in men. Because of
its chronicity, dysthymia is among the most prevalent psychiatric conditions in clinical practice. Dysthymia
is more disabling, as far as quality of life in social and personal areas, work, and leisure, than depression in
the setting of a severe anxiety disorder like agoraphobia. Celibacy is also common in early-onset dysthymia,
but not for long; modern successful treatments often lead to a change in marital status!
UCLA research in primary care has focused on depressive symptoms falling short of the major depressive
threshold, as far as symptom intensity is concerned, as well as falling short of the two year duration
criterion for dysthymia. Despite its chronicity, 50 per cent of people remain unrecognized by general
practitioners. Despite the low-grade nature of their depressive complaints, these patients report high
degrees of morbidity and impairment in a variety of health domains and quality of life, including ‘bed days’
(namely, the number of days per year they stayed ill in bed). Actually, these impairments are generally more
pronounced than those of patients with a variety of medical conditions, such as hypertension, diabetes,
arthritis, and chronic lung disease; only coronary artery disease exceeded the disability of low-grade
depression in several domains. Stroke has recently been added on this list.
(21)
In light of the foregoing developments, both the World Psychiatric Association and the World Health
(22)
Organization have developed programmes to address the challenges of educating general practitioners in
the proper recognition and treatment of dysthymia.
Aetiological considerations(20)
Some sensitivity to su ering, a cardinal feature of the depressive temperament, represents an important
attribute in a species like ours, where caring for young and sick individuals is necessary for survival. This
temperament, historically the Anlage of dysthymia, in the extreme often leads to clinical depression. The
constitutional viewpoint, while dominant in the early part of the twentieth century, gradually disappeared
from psychiatric thinking. One reason was that Kurt Schneider preferred to conceptualize such conditions as
‘psychopathy’, by which he meant abnormal personality development. Independently, Freud's disciples
took this one step further and, eventually in outpatients, all milder depressions with a tendency to

chronicity came to be considered as the expressions of a character neurosis. In support for this position,
these authors could point to the long-standing nature of the interpersonal di culties in the lives of these
individuals. When, and if, antidepressants were prescribed, they were given in homeopathic doses; worse,
many patients received stimulants or benzodiazepines rather than genuine antidepressants. Failure to
respond to these incorrectly chosen pharmaceutical agents seemed to further reinforce the notion of a
‘character’ defect.
Several lines of observation during the latter part of the 20th century have challenged the concept of
‘character neurosis’ as an explanation for low-grade depression, and thereby forced a return to the more
classical European concept of temperament with its biological underpinnings. First, in a 1980 Memphis
study of rapid eye movement (REM) latency (normally 90 min, measured from sleep onset to the rst REM
period) conducted in ‘depressive characters’ who were not in a state of major depression, we reported that
REM latency was less than 60 min, and REM was redistributed to the early part of the night (which was the
reverse of what we observed in chronic anxious patients). Moreover, a family history for major a ective
illness (including bipolar) was signi cantly high in short-REM latency patients. (The reverse was true for
those with familial alcoholism and sociopathy.) The sleep ndings were so reminiscent of those seen in
major a ective illness that we were compelled to give our patients systematic open trials with desipramine
and nortriptyline (the best-tolerated secondary amine tricyclics in those days) or lithium carbonate if
antidepressants failed (based on the observation of familial bipolar disorder in some). Nearly 40 per cent
remitted, of whom one out of three developed brief hypomania. The sleep ndings have been replicated in
other laboratories. Furthermore, a Hungarian study has shown that patients with dysthymia experience
transient lifting of their mood with sleep deprivation. Other studies have shown high rates of a ective
illness in a systematic familial investigation of dysthymic probands. There also exist dysthymic patients
whose lifelong su ering and discontent appear, in retrospect, a legacy of an unsatisfactory childhood
marked by deprivation or abuse at the hands of alcoholic and/or sociopathic parents or step-parents.
Although it is clinically attractive to invoke the notion of ‘learned helplessness’ secondary to such
inescapable childhood traumata, an alternative hypothesis is that the helplessness of these individuals
might develop secondary to an inherited diathesis which biases these children's early experiences in a
dysphoric direction.
As for neuroendocrine markers, thyroid-releasing hormone- thyroid-stimulating hormone challenge and

electrodermal activity similar to those with major depressive disorders are the main ndings; by contrast,
dexamethasone suppression and catecholamine metabolism are essentially unaltered in dysthymia. These
observations, along with the REM latency ndings, suggest that dysthymia represents trait depression.
Coupled with the family history data, this traitness can be postulated to be of constitutional origin.
Certainly, the occurrence of major a ective episodes in the long-term course of dysthymia, in both
community and clinical samples, is in line with this position. It is, therefore, of great theoretical and
practical signi cance that shortened REM latency has been reported in the o spring of the a ectively ill.
More recently a variety of other biological ndings have been reported in dysthymia, further strengthening
(24)
the link with major depression: low testosterone and adrenal-gonadal steroid levels, neuro-immune
(25) (26)
abnormalities, e ects of prenatal maternal dysthymia on foetal growth, as well as small genual corpus
(27) (28)
callosum volume and enlarged amygdalar volume. Coupled with s-allele polymorphism of the
(29,30)
serotonin transmitter, that subthreshold depression, however de ned, is not a ‘neurotic’ phenomenon
in the traditional psychodynamic sense of the term, but part of the spectrum of depressive illness! Table
4.5.9.2 summarizes the foregoing links between dysthymia and major depressive disorder, and which
support its inclusion within the family of mood disorders.
Table 4.5.9.2 Evidence for considering dysthymia as a variant of major depressive disorder
Familial a ective loading

Phase advance of rapid eye-movement sleep
Diurnality of inertia, gloominess, and anhedonia
Thyroid-releasing hormone-thyroid-stimulating hormone challenge test abnormalities
Low testosterone
Lowered interlukin-1-beta production
Amydalar enlargement
s-allele in serotonin transporter gene
Prospective course complicated by recurrent major depressive episodes
Positive response to selected thymoleptics
Treatment-emergent hypomania
(19)
Updated from Akiskal.
There are also exist medical and neurological factors that may contribute to dysthymic symptom formation.
Actually, joint medical-neurological and non-a ective psychiatric disease is often contributory to extreme
refractoriness among the chronic depressive states of these patients. Such patients are at risk for suicide,
especially those with epilepsy or progressive degenerative neurological disease. Interestingly, living with a
medically disabled spouse or family member, too, can be associated with some chronicity of depression.
The emergence of pathogenetic understanding, as outlined above, is all the more impressive, given the
(31)
controversies on the very nature of dysthymia and its legitimacy as a nosological entity.
Treatment(20)
The trait nature of dysthymia can be further observed in the fact that dysthymia often pursues an
unrelenting course towards chronicity. Thus, spontaneous recovery has been shown to occur in no more
than 13 per cent of subjects in the community over 1 year. In outpatient clinics, the outcome is somewhat
better, but this is probably due to the treatment received and a longer follow-up.
Most classes of antidepressants have been shown to be e ective in dysthymia in double-blind studies (Table
4.5.9.3). The rationale for using classic antidepressants such as tricyclic compounds in our mood clinic was
our observation of shortened REM latency in dysthymic subjects in our sleep laboratory. Irreversible
monoamine oxidase inhibitors such as phenalzine were used because of the belief that non-classical
depressions respond preferentially to this class of drugs; the same can be said for the reversible inhibitors of
type A monoamine oxidase. Amisulpride was tried, because it reverses ‘negative’ symptoms in
schizophrenia and, by analogy, it was hypothesized that the low motivation and lethargy seen in some
patients with dysthymia re ected a shared underlying dimensional transnosological pathology. The
selective serotonin re-uptake inhibitors (SSRIs) were used empirically, because of good tolerance compared
with the tricyclic antidepressants, and later it was suggested that improvement in dysthymia correlates with
normalization of serotonergic indices. The foregoing trials, conducted in di erent countries during the past
12 years represent the most eloquent evidence for the increasing worldwide acceptance of the concept of
(21,22)
dysthymia as a clinically signi cant variant of a ective disorder.
Table 4.5.9.3 Major controlled pharmacological trials in dysthymia worldwide*

Reference Country Medication
Vallejo et al. (1987) Spain Phenelzine versus imipramine
Kocsis et al. (1987) USA Imipramine versus placebo
Stewart et al. (1989) USA Phenelzine versus placebo
Thase et al. (1996) USA Sertraline versus imipramine
Vanelle et al. (1998) France Fluoxetine versus placebo
Lecrubier et al. (1996) France Amisulpride versus placebo
Versiani et al. (1997) Brazil Moclobemide versus imipramine
(19,20)
* Summarized from references
The treatment of dysthymia should continue in most cases for 2 years or more. Tricyclic antidepressants
have too many side-e ects in clinically e ective doses (desipramine equivalent of 150 mg or more per day).
Given dietary and medication prohibitions, monoamine oxidase inhibitors are also not practical as rst-line
drugs. Overall good tolerance in long-term use, despite sexual side-e ects, has made the SSRIs rst-line
intervention treatment for dysthymia; given that many people with dysthymia are young individuals who
should be eager to form families, their acceptance of long-term SSRI use is an indication that the alleviation
of the depressive su ering of dysthymia is genuine and far outweighs the sexual dysfunction. However, 75
to 150 mg bupropion-SR can be taken in the morning on the desired day of sexual union, but preferably no
more than once a week. Moclobemide also spares sexual function, but seems more e ective in anxious and
milder cases of dysthymia. Amisulpride, which rarely causes amenorrhoea and/or galactorrhoea, is
otherwise well tolerated in dysthymia in the more lethargic forms of the illness seen in general medical
practice.
The dosage of nearly all antidepressants in dysthymia is in the full range for that recommended for major
depression (20–40 mg for uoxetine). In the case of amisulpride, the dosage is low (25–50 mg), because at
this dosage the drug is a dopamine agonist, believed to be the necessary ingredient for its mechanism of
action in dysthymia. Both dysthymia and double depression respond equally well, and the duration of
underlying dysthymia does not seem to matter. The main di erence in treatment for these two course
patterns is that dysthymia need not be treated for a lifetime, but double depression should probably be
treated inde nitely. Women seem to have a preferentially better response to SSRIs, which have the added
bene t of treating the premenstrual accentuation of dysthymic symptoms. Borderline thyroid function (e.g.
a high baseline thyroid-stimulating hormone level) preferentially occurs in women with dysthymia, so that
these women would bene t from thyroid augmentation (levothyroxine 175 mg/day) of the antidepressant.
In those patients who oversleep in the morning, terminal sleep deprivation and/or morning phototherapy
represent useful adjuncts to antidepressants. Although there are no controlled studies in children, our
clinical experience indicates that SSRIs often prove e ective in this population, with the appropriate dosage
reduction for body-weight. In adults, concurrent personality disturbances (for instance, obsessoid,
avoidant, dependent, and hostile features) do not compromise therapeutic responses. Indeed, more often
than not, such personality disturbances recede with the successful alleviation of dysthymic su ering; social
function improves in tandem. (However, extremely hostile patients, who may meet symptomatological
criteria for ‘dysthymia’ but whose irritable dysphoria more appropriately belongs to the cyclothymic
domain, are best managed with mood-stabilizing anticonvulsants, for example divalproex 600 to 1200
mg/day.)

In a Memphis study, we have shown that, with the judicious use of the foregoing modalities in private
practice, three out of four patients with dysthymia engulfed in gloom for much of their lives had sustained
remissions for ve or more years. Depressive episodes and suicidal preoccupation and/or crises were
prevented, in tandem with the alleviation of the dysthymia. Approximately 15 per cent experienced
‘overcorrection’ of their dysthymia in the direction of mild hypomania; this is particularly likely in the
presence of inhibited-social phobic traits as part of dysthymia, and when the family history is bipolar. The
hypomania is typically short-lived, and tends to disappear when the antidepressant dose is reduced; in
some cases, it is necessary to provide lithium (600–900 mg/day) or valproate augmentation (500–750
mg/day). The question has been raised whether selective serotonin-reuptake inhibitors, in particular
uoxetine, change the personality in a hyperthymic direction. In our experience, most observed changes are
compatible with adaptive behaviour that emerge as a result of alleviation of depressive su ering; the more
distinctly protracted hypomanic changes nearly always require familial bipolar diathesis. It is, nonetheless,
true that with SSRIs we have entered an era of ‘dimensional psychopharmacology’, whereby the clinician
could dose the patient to a desired end from a functional standpoint. Many become care-less rather than
careless. The present author has also encountered some patients treated with SSRIs who view a life without
cares as negative; in such cases, one should opt for very low doses and a more gradual lifting of the
dysthymia, and help the patient adjust to a new self-image of normalcy.
As for psychotherapy, there is little credible evidence for its e cacy as monotherapy in the treatment of
dysthymia. Actually, some female mental health experts have argued that exploration of one's mental
inadequacies, in the ‘passive’ psychoanalytical situation, is particularly negative for women; the more
‘active’ cognitive behavioural approaches, which encourage thinking, and behaviours reinforcing for the
individual, are preferable. Many clinicians pro tably use the latter strategy along with pharmacotherapy to
boost the self-esteem of the patient. In a more practical vein, there are clinical management strategies that
are speci cally useful for both the patients and their clinicians (Table 4.5.9.4). It is particularly important
for the clinician not to be submerged by the negative thinking of the patient, and it is even more crucial for
the therapist to recognize that a relative lack of progress can generate feelings of ‘impotence’ and
countertransference; periodic consultation with more experienced clinicians in the treatment of chronic
depression would be desirable.
Table 4.5.9.4 Psychotherapeutic principles in dysthymia*
Provide a believable dose of optimism
Optimize compliance to pharmacotherapy
Limit destructive expression of negative feelings
Address accumulated conflicts
Combat postdepressive resignation and inertia

Provide support for patient and significant others
Be aware of countertransference feelings
Consult experts with extensive experience in treating chronic depression
Gradually mobilize patient's skills and resources
(6)
* Updated from Akiskal.
Interpersonal psychotherapy has been used in medication failures. This is best viewed as a more practical
abbreviation of psychodynamic psychotherapy, with a strong emphasis on support and encouragement for
patients with dysthymia who seek help at a time of loss or role transition in their lives. Knowledge of the
interpersonal context of depression is obviously important in formulating how the clinician would stage the
psychological recovery process from dysthymia. Nonetheless, there are some suggestions that SSRIs often
lead to improved coping behaviour, even without formal psychotherapy. Indeed, Canadian studies have
shown that a successful response to SSRIs is often associated with decreased emotion-focused coping and
decreased perception of daily hassles, as well as alleviation of the sense of loneliness one experiences in
chronic depression.
No matter what the active ingredients in antidysthymic treatments, there is little doubt that for the rst
time in the history of psychiatry we have potent practical treatments to alleviate a major source of chronic
human su ering, including what were once deemed depressive characterological attributes inseparable
from the habitual self. Helping patients attain a new homeostasis of the self is an art unparalleled in the
history of medical science. In our view, it does not constitute what Kraemer has erroneously labeled
(32)
‘cosmetic psychopharmacology’.
Prevention opportunities(20)
Community subjects with pure dysthymia have been found in two prospective studies to be at risk for major
depressive episodes. Because dysthymia often makes its rst appearance in juvenile years, identifying the
disorder at this early stage represents a special opportunity for prevention in child psychiatry and
paediatrics. ‘Pure’ dysthymia, even without major depression, responds better to pharmacotherapy better
than to placebo in 8 out of 9 social domains. St. John's Wort, on the other hand, does not appear to be
(33)
e ective in dysthymia!
In still another group of patients, low-grade chronic depressive developments occur in the setting of
disabling systematic medical and neurological disorders, and are best categorized as ‘secondary
dysthymias’. For instance, poliomyelitis may not only lead to deformities in musculoskeletal structures in
children, but could permanently scar the su erer's sense of enjoyment, ful llment, and outlook of life.
Likewise, low-grade chronic depressive development often complicates neurodegenerative cerebrovascular
disease later in life. In both situations, psychological factors might be operative, yet the contribution of
speci c cerebral lesions to the subthreshold mood disturbance may be substantial. This group as a whole is
not well captured by the conventional depressive cate-gories in ICD-10 and DSM-IV. In these subacute
dysthymic-like conditions, the a ective state is often disabling, yet symptomatologically less severe than
major depression; it is low grade, yet not as chronic as dysthymia. ‘Minor depression’ would not capture the
clinical signi cance of their condition. Indeed, there is emerging data that treating these subacute
(22)
dysthymias may improve the prognosis of the underlying neurological disorder.
In concluding this review of the legitimacy of dysthymia from clinical, biologic and therapeutic standpoints,

it is relevant to point out that dysthymia—properly de ned—may well serve as a behavio-ral
(34)
endophenotype for depressive illness. Such a conceptualization highlights its potential as a target for
preventing strategies for major depressive illness.
Cyclothymic disorder and labile-irritable variants(20)
History
Kraepelin included the cyclothymic disposition as one of the temperamental foundations from which
manic-depressive illness arose. Kretschmer went one step further and proposed that this constitution
represented the core characteristic of the illness: some patients were more likely to oscillate in a sad
direction, while others would more readily resonate with cheerful situations; these were merely viewed as
variations in the cyclothymic oscillation between these two extremes. Kurt Schneider, who did not endorse
the concept of ‘temperament’, instead referred to ‘labile psychopaths’ whose moods constantly changed in
a dysphoric direction, and who bore no relationship to patients with manic depression. To confuse matters
further, Schneider used the term ‘cyclothymia’ as a synonym for all manic depressive illness, from the
mildest to the most severe psychotic forms. Today, ‘cyclothymia’ is still sometimes used in this broader
sense in Germanophone psychiatry. But in much of the rest of the world, cyclothymia (short for
‘cyclothymic disorder’) is reserved for a form of extreme temperament related to bipolar disorder.
Cyclothymia, which in ICD-9 and DSM-II was subsumed under the a ective personalities, was rst
introduced into DSM-III and DSM-IV and subsequently into ICD-10 as a form of attenuated chronic mood
disorder. The diagnosis is not commonly made in clinical practice, because it is almost always seen when a
patient presents with major depressive episodes, warranting the designation of ‘bipolar II’. Indeed, Hecker
used cyclothymia as a synonym for what today we call bipolar II; his short monograph has recently been
(35)
translated into English. Nonetheless, systematic clinical and familial validation studies conducted in
(36,37)
Memphis have shown that the construct of cyclothymic temperament is of great theoretical,
psychometric and practical signi cance as one of the possible substrates for major mood disorders.
Moreover, it could shed light on social and occupational maladjustment and/or addictive behaviours that
could otherwise be misattributed to personality disorder.
Clinical features and diagnostic considerations(20)
By de nition, individuals with cyclothymia report short cycles of depression and hypomania that fail to
meet the sustained duration criterion for major a ective syndromes. At various times, they exhibit the
entire range of manifestations required for the diagnosis of depression and hypomania, but only from a few
days at a time up to 1 week, rarely longer. These cycles follow each other in an irregular fashion, often
changing abruptly from one mood to another, with only rare interposition of ‘even’ periods. The
unpredictability of mood swings is a major source of distress for cyclothymes, as they do not know from
moment to moment, how they will feel. As one patient put it, ‘my moods swing like a pendulum, from one

extreme to another’. The rapid mood shifts, which undermine the patients’ sense of self, may lead to the
misleading diagnostic label of borderline personality. But unlike a personality disorder, the mood changes
in cyclothymes have a circadian component. One patient described it as follows: ‘I would go to bed in a
cheerful mood and wake up down in the dumps’. This observation is in line with NIMH psychophysiological
data on mood-switching occurring out of the rapid eye movement sleep phase, as reported in more typical
cases of manic depression.
The mood swings of cyclothymes are biphasic: eutonia versus anergic periods; people-seeking versus self-
absorption; sharpened thinking versus mental paralysis. Table 4.5.9.5 provides an empirically tested set of
criteria. In addition, the following presentations characterize their roller-coaster biography.
Table 4.5.9.5 Discriminatory biphasic characteristics of cyclothymic disorder*
Lethargy alternating with eutonia
Shaky self-esteem alternating between low self-confidence and overconfidence
Decreased verbal output alternating with talkativeness
Mental confusion alternating with sharpened thinking
Introverted self-absorption alternating with uninhibited people-seeking
(36,37)
* Summarized from Akiskal et al.
Irritable periods. At one time or another, labile angry or irritable moods are observed in virtually all these
patients. Cyclothymes, unlike patients with epilepsy, are aware of their ‘ ts of anger’, which lead to
considerable personal and social embarrassment after they subside. The patients often feel ‘on edge,
restless, and aimlessly driven’; family and friends report that during these periods patients seem
inconsiderate and hostile toward people around them. The contribution of alcohol and sedative-hypnotic
drugs to these moods cannot be denied, but the moods often occur in the absence of drugs.
Electroencephalography typically reveals no seizure or subseizure activity. The interpersonal costs of such
unpredictable interpersonal explosiveness can be quite damaging. One of our patients reported frequent
periods where he would start unprovoked ghts with very close friends, only to shift into periods of
prolonged ‘soul-searching, guilt, shame, and embarrassment’. In other patients, outbursts of anger are
‘reactive’ to minor interpersonal disputes—but once in full force, they are like emotional avalanches with
the distinct potential to destroy relationships. Should they dominate the clinical picture, especially among
young women who hurt themselves in response to interpersonal contexts, the problematic diagnosis of
borderline personality disorder is often invoked (more so in North America than elsewhere). Although
controversial, contemporary research suggests that many ‘borderline’ patients represent a severe labile-
(38)
irritable variant of cyclothymia on the border of manic-depressive psychosis. On the other hand, bizarre
episodes of self-harm with features of post-traumatic stress are uncharacteristic of cyclothymia, and
suggest other diagnoses.
Romantic–conjugal failure. It is easy to understand how individuals with mercurial moods would charm
others when in an expansive people-seeking mode, and rapidly alienate them when dysphoric. In e ect, the
life of many of these patients is a tempestuous chain of intense but brief romantic liaisons, often with a
series of unsuitable partners. Some rationalize their behaviour on the grounds that their spouse or partner is
‘too conservative in sex, too unimaginative, too unaware of the intensity’ needed to stimulate them. As
expected, frequent marital separations, divorces, and remarriage to the same person occur.

Financial extravagance. One patient in our case series reported going to bars and buying people drinks
because he wanted everybody to feel like him. Another patient intermittently showered his lovers with
expensive jewellery. In general, however, the extravagance of the cyclothymic group re ects gregariousness
and tends to occur on a smaller scale compared to the psychotic manner in which manic patients bring
nancial ruin to themselves and their families.
Uneven school and work record. Repeated and unpredictable shifts in work and study habits occur in most
people with cyclothymia, giving rise to a dilettante biography. Although some do better during their ‘high’
periods—for example, one car salesman would sell cars only ‘when up’—for others, the occasional ‘even’
periods were more conducive to meaningful work. It is sometimes unappreciated by clinicians
inexperienced with bipolarity that the hypomanic period can be one of disorganized and unpatterned
busyness that could easily lead to a serious drop in net productivity. For instance, one insurance salesman
related that he was less successful when ‘high’, because he tended to enter into unproductive arguments
with his clients. When ‘down’, productivity obviously abates, although two creative individuals in our case
series—one inclined poetically, the other towards painting—produced their better work when coming out
of mini-depressions.
Alcohol and drug abuse. An alternating pattern of the use of ‘uppers’ and ‘downers’ occurs in at least 50 per
cent of patients. We have clinically evaluated at least ve cyclothymes who ‘sold dope’ to maintain their
habit: two went to prison. These and other observations suggest that a proportion of substance-abusing,
especially stimulant-abusing, patients might be su ering from subtle or cryptic forms of bipolar disorder.
The bipolar nature of mood swings in alcohol- or substance-abusing individuals can be documented by
demonstrating mood swings well past the period of detoxi cation; in some cases, escalating mood
instability makes its rst appearance following abrupt drug or alcohol withdrawal. The DSM-IV criteria for
drug-induced or drug withdrawal-induced mood disorder are, in our opinion, biased against the diagnosis
of otherwise treatable bipolar spectrum disorders. New evidence suggests that the temperamental disorder
might serve as the anlage for self-enhancement or augmentation with cocaine, other stimulants and heroin.
(39,40)
These features might raise di erential diagnostic questions from adult attention de cit hyperactivity
disorder (ADHD). The social warmth observed among most people with cyclothymia distinguishes them
from ADHD. Also, elation and in ated self-con dence, which occur periodically in cyclothymia, are
uncharacteristic of ADHD; the moodiness in the latter is largely depressive in nature. Finally,
antidepressants and stimulants typically worsen the moods in cyclothymia; they treat ADHD. In rare cases,
however, cyclothymia and ADHD can coexist.
Course patterns
In cyclothymia, hypomania and mini-depression alternate with each other from adolescence. For instance,
the optimistic, overcon dent, people-seeking phase can give way to self-absorption, self-doubt,
pessimism, and a sense of futility, emptiness, and suicidal ideation. More commonly, depressive periods
dominate the clinical picture, interspersed by ‘even’, ‘irritable’, and occasional hypomanic periods. Indeed,
most people with cyclothymia who present clinically do so because of depression. These depressions are
typically short-lived, yet unrelenting in their cyclic course, creating much interpersonal havoc for the
patient. The following vignette illustrates the cardinal clinical features of cyclothymia that has not yet

progressed to major depression.
Case Study: This 24-year-old songwriter presented with the chief complaint of ‘depression so bad that I
become totally dysfunctional—I cannot even get out of bed’. Since her mid-teens she had experienced
periods lasting from a few days up to a week, during which she would withdraw into herself, losing
con dence and interest, feeling drained of energy, and crying when approached by anybody. These periods
were particularly prevalent during the autumn and winter months, but they did not coincide with the
premenstrual phase. All she needed sometimes was restful sleep to ‘feel alive again’; at other times, she
would have little sleep, and would wake up ‘wired’, ‘ready to go’, ‘open to experience all the joy waiting for
me out there’; she would exude con dence, ‘sensuality and sexual aroma’. These occurred less frequently
than the ‘down’ periods and usually lasted for 1 to 3 days, but were not associated with creative spurts. The
latter came as she was descending from ‘highs’ into a more ‘mellow depression’. Her success in music had
been sporadic, paralleling the sporadic nature of her ‘muses’ that visited her on the descending limb of
‘hypomania merging with tears’. However, the major toll of her mood swings had been in her personal life,
the intensity of her moods had driven away most men she had loved, of whom she had lost count. She
described periods of such intense sexual arousal, that sometimes she would go to bed ‘with anybody,
including women of all ages, shapes, and description’. But, she added: ‘I am not a lesbian—oral love is just
one way of relating to these women—why not?’ She had also experimented with drugs, such as stimulants,
which had made her moodiness worse. More recently, she had been prescribed at least two SSRIs, which
after a period of ‘success’ for a few months, had made her depressive swings more frequent and lower in
amplitude, leading to the present consultation in our clinic.
As documented in this case, sexual excesses with both sexes are often readily admitted by patients. Winter
accentuation or clustering of depressive periods, as exempli ed here, is not uncommon in cyclothymia. We
also would like to point out the special relationship of the moods to artistic productivity which occur in up to
(41)
8 per cent of cyclothymic depressions. The 4-day threshold for hypomania in the o cial diagnostic
manuals is too con-servative; as shown in this case, most patients with cyclothymia (and bipolar II
disorder) report a threshold of 1 to 3 days (though on occasion, one would observe a hypomanic duration of 1
week or longer). It is also noteworthy that the episodes are short-lived and do not reach the duration
threshold for rapid cycling. Sometimes, the term ‘ultra rapid cycling’ is used for these patients, but we
prefer to reserve this for extremely severe cases who require hospitalization. The short cycle length in
cyclothymia is, in part, a selection artifact: the universe of patients with bipolar disorder is composed of an
extreme variety of overlapping patterns.
The relationship of a cyclothymic temperament to the bipolar spectrum is more complex than that of
dysthymia to major depressive disorder. Although cyclothymia can be observed in some patients with full-
blown manic-depressive illness (bipolar I with severe or hospitalized mania), it is more commonly
associated with the bipolar II pattern (of recurrent major depression with self-limited hypomanias). In a
recent French national study of patients with major depression, 88 per cent of those with a cyclo-thymic
disposition belonged to the bipolar II subtype. (Mania, by contrast, has been reported to more likely
represent either an extension of hyperthymic traits, or a reversal from a depressive temperamental
baseline.)
One-third of patients with cyclothymia studied by us on a prospective basis, progressed to spontaneous
(36,37)
a ective episodes with more protracted hypomanias and clinical (major) depression. Thus, 6 per cent
of the original cyclothymic cohort could be reclassi ed as bipolar I, and 30 per cent as bipolar II. The
tendency to switch to hypomania was further augmented by the administration of antidepressants. A larger
National Institute of Mental Health study of patients with major depression who switched to bipolar II
during a prospective observation period of up to 11 years, found that a temperamental mix of ‘mood-labile’,
‘energetic-active’, and ‘daydreaming’ traits (reminiscent of Kretschmer's concept of the cyclothymic
temperament were the most speci c predictors of such outcome. Actually such temperamental factors
predict who among the o spring of bipolar probands will progress during prospective course to clinical

(42)
episodes. New data further indicate that cyclothymia might be one of the pathways to suicidality among
(42)
adolescents.
The foregoing clinical and course characteristics suggest that a cyclothymic temperament leading to major
depressive recurrences represents a distinct longitudinal pattern of ‘cyclothymic depression’, and which
appears to capture the core features of bipolar II disorder in contemporary clinical practice. Because
hypomanic episodes cannot be easily ascertained by history, assessing cyclo-thymia in clinically depressed
patients represents a more sensitive and speci c approach to the diagnosis of bipolar II.
Epidemiology
An excess of interpersonal di culties and psychiatric consultations distinguish people with cyclothymia in
the community from controls; excessive use patterns of stimulants, ca eine, nicotine, and alcohol, have
also been well documented. Explosive traits, probably representing the irritable component of cyclothymia,
have been reported to be prevalent in the community in a British study. More recently, we found that 6.3 per
cent of a national cohort of 1010 Italian students between the ages of 14 and 26 years of age scored above two
standard deviations for cyclothymia; this was more prevalent in females, with a ratio of 3:2. Overall, the
foregoing data testify to the fact that a cyclothymic and/or labile disposition can be accurately measured, is
prevalent, and represents a population at risk for a ective disorders. Table 4.5.9.6 summarizes the rates in
di erent populations.
(20)
Table 4.5.9.6 Prevalence of cyclothymic and related mood-labile temperaments *
Reference Population (Country) Rate (%)
Akiskal et al. (1977) Mental health centre (USA) 10
Weissman and Myers (1978) Community (USA) 4
Depue et al. (1981) College students (USA) 6
Casey and Tyrer (1986) Community (UK) 6
Wicki and Angst (1991) Community (Zurich) 4
Placidi et al. (1988) 14–26–year old students (Italy) 6
* These data derive from interview-based studies. For more recent psychometric data based on cyclothymic and a broader
(8)
range of sub-bipolar temperaments in a self-reported format can be found in a new monograph.
Aetiological aspects
The amboyant behaviour and the restless pursuit of romantic opportunities in cyclothymia suggest the
(23)
hypothesis that its constituent traits may have evolved as a mechanism in sexual selection. Even their
creative bent—in poetry, music, painting, or fashion design—may have evolved to subserve such a
mechanism. Cyclothymic traits appear to lie on a polygenic continuum between excessive temperament and
manic depression. Indeed, clinically identi ed cyclothymes have patterns of familial a ective illness, as one
would expect for a forme fruste disorder.

Cyclothymia has also been observed in the o spring of manic-depressive probands, with onset in the
postpubertal period. Finally, family studies of patients with a bipolar disorder have revealed an excess of
cyclothymia. Hypothetically, this temperament might represent one of, if not the most important, inherited
trait diathesis for bipolar disorder. For instance, moody- temperamental individuals are over-represented
in the ‘discordant’ monozygotic co-twins of Danish manic-depressives. Alternatively, and in a more
theoretical vein, manic-depressive illness might be the genetic reservoir for the desirable cyclothymic traits
(23,44)
in the population at large. In line with these data and considerations, cyclothymia can be considered a
(45)
behavioral endophenotype for bipolar disorder. This is supported by recent ndings from both Europe
and the United States which have shown that it is present in the clinically well relatives of bipolar probands.
(40) (46)
Cyclothymia might also share familial-genetic relationship with alcohol and substance use, bulimic,
(47) (48) (49)
panic, obsessive-compulsive as well as atypical depressive and borderline conditions.
Clinical management
The proper pharmacological treatment for cyclothymic excesses is low doses of lithium (600–900 mg/day)
(50)
or valproate (500–750 mg/day). These are based on open systematic studies. There is some data from a
controlled trial with lithium about the prevention of depression in cyclothymic individuals. Similarly
controlled data exist for a related construct—‘labile personality’. Generally speaking, patients with
cyclothymia object to the ‘overcontrol’ that may come from mood stabilizers, and this is particularly the
case with lithium. Lamotrigine is also being used on clinical grounds in the unstable dysthymic-cyclothymic
spectrum. In those with ‘borderline’ features, lamotrigine is particularly promising.
Patients should be taught how to live with the extremes of their temperamental inclinations, and to seek
professions where they determine the hours that they work. Marriage to a work-oriented or a rich older
spouse might sustain them for a while, but eventually interpersonal friction and sexual jealousy terminate
such marriages. The artistically inclined among them should be encouraged to live in those parts of a city
inhabited by artists and other intellectuals, where temperamental excesses are better tolerated. ltimately,
the decision to use mood stabilizers in such individuals should balance any bene ts from decreased mood
instability against the social and creative spurts that the cyclothymic disposition can bring to them. Their
clinical management represents a challenging task for the psychiatrist who is willing to learn about the
lifestyle of these individuals, not prejudging them by the more mundane norms of society. But the
psychiatrist should also be there to help them during the multiple crises of their lives. Low-dose sedating
neuroleptics, both classical (e.g. thioridazine 50 mg at bedtime) and atypical (e.g. quetiapine 25–50 mg at
bedtime) may temporarily help to di use such crises. It is only when a clinician has earned therapeutic
alliance with a patient that the latter will permit limit-setting on his or her extravagant or outrageous
behaviour. Parents might also bene t from some counselling, because the dilettante life of their children is
often a source of great sorrow for them. Rarely, parents or spouses are rewarded by great artistic or
intellectual achievement, which does not necessarily reduce the pain that the volatile cyclothymes bring to
their loved ones.
Kurt Schneider admonished the kin of labile individuals (who might approximate the contemporary concept
of borderline personality disorder) ‘on their bad days … to keep out of their way as far as possible’.
Cyclothymes with some insight into their own temperament would give the same advice to their loved ones.
A cautious trial of anticonvulsants will often prove e ective in those distressed enough by their behaviour to
comply with such treatment.
Prevention
The o spring of patients with bipolar disorder who exhibit a cyclothymic level of temperamental

dysregulation represent a logical population for prevention studies. This is a challenge for the 21st century.
Presumably molecular genetic testing will one day identify those moody individuals who carry the genes for
bipolar disorder. At present, it would be useful to conservatively follow- up the cyclothymic o spring of
people with bipolar disorders and provide them with psychoeducation about the necessity of avoiding
stimulants and sleep deprivation. It may not be entirely possible to prohibit the use of occasional alcohol
consumption, but benzodiazepines should not be used. It is also imperative, should they get depressed, to
protect them from the indiscriminate prescription of antidepressants.
Mood-labile female prisoners, commonly given the diagnosis of antisocial or borderline personality
disorder, may represent a ective variants with irritable cyclothymic features. Formal studies are needed in
prison populations, to assess more precisely the rates of preventable cryptic bipolarity among female and
male o enders.
It is nally worthwhile to mention that a ective temperaments with irritable, cyclothymic and irritable-
hyperthymic traits might predispose to HIV infection. The public health dimensions of this question deserve
further research focus.
The hyperthymic temperament(38)*
History and description

Although well described by classical German psychiatrists (e.g. Schneider), the hyperthymic type appears
neither in DSM-IV nor in ICD-10. A lifelong disposition, hyperthymia must be distinguished from short-
lived hypomanic episodes. Alternatively, this disposition can be characterized as trait hypomania. It derives
from the ancient Graeco-Roman sanguine temperament, believed to represent the optimal mixture of
behavioural traits. They are full of zest, fun-loving, and prone to lechery: their habitual disposition is one of
buoyant action-orientation, extraverted people-seeking, overcon dence, and swift thinking. Typically
short sleepers, they possess boundless energy to invest in sundry causes and projects, which often earn
them leadership positions in the various professions and politics, yet their carefree attitudes and propensity
for risk-taking can bring them to the brink of ruin; this is particularly true for their nances and sexual life,
which can be marred by scandal. A hyperthymic lifestyle is so reinforcing that some resort to ‘augmenting’
it with stimulants such as amphetamines or cocaine. In brief, while a hyperthymic temperament per se does
not constitute a ective pathology—indeed, it represents a constellation of adaptive traits—in excess it
could lead to undesirable complications. The latter will be our main focus here.
Epidemiology
The foregoing considerations partly explain why such a temperament has received scant research attention
in the community. Extrapolating from studies on intermittent hypomania in the community, if strictly
limited to hypomania with early onset and persistent course, the prevalence of hyperthymic temperament
can be estimated to be slightly under 1 per cent. On the other hand, the traits that constitute the
hyperthymic pro le are so desirable that normal individuals tend to endorse them; in a recent Pisa-San
(16)
Diego collaboration involving 1010 students aged between 14 and 26, of whom 8.2 per cent met the full
criteria for hyperthymic temperament, all participants scored between the rst and second positive

(51) (52)
standard deviation. The TEMPS-A tends to validate these ndings in Lebanon, Argentina and Hungary.
(53)
More work needs to be done on the psychometric standardization of this temperamental construct; on
the other hand, all studies are consistent in showing marked male predominance.
Diagnostic aspects
On the positive side, hyperthymic individuals are enterprising, ambitious, and driven, often achieving
considerable social and vocational prominence. Abuse of stimulants is not so much an attempt to ward o
depression and fatigue as an e ort to enhance their already high-level drive and, sometimes, to further
curtail their already reduced need for sleep. Hyperthymic individuals typically marry three or more times.
Others, without entering into legally sanctioned matrimony, form three or more families in di erent cities;
these men are capable of maintaining such relationships for long periods, testifying to their nancial and
personal resourcefulness, as well as their generosity towards their lovers and the o spring from such
unions. Unlike the antisocial psychopath who is predatory on others and neglects or abuses his women and
children, these men care for their loved ones. But obviously, the ‘arrangement’ involving women of
di erent generations is complex, and a fertile soil for jealousy, drama, scandal, and tragedy. Nonetheless, it
is not uncommon to see more than three or four women crying profusely and expressing their common
grief at the funerals of these men!
Although individuals with hyperthymia optimally enjoy the advantage of their reduced need for sleep
(giving more time and energy to invest in work and pleasure), some present clinically because of insomnia.
(54)
Thus, in a predominantly male sample of executives presenting to a sleep centre, habitual sleep need was
4 to 5 h; however, they had been intermittently bothered by ‘nervous energy’ and di culty falling asleep.
Now, in late middle age, alcohol was no longer an e ective hypnotic. Although they vigorously denied
depressive and other mental symptoms—indeed, they had extremely low scores on self-rated depression—
spouses or lovers provided collateral information about brief irritable-depressive dips, especially in the
morning and, in some cases, more protracted ‘fatigue states’ of days to weeks during which the subject
would vegetate. Despite these depressive dips, these patients were distinguished from the constantly
shifting moods of cyclothymic patients by the fact that the depressions arose from a baseline of trait
hypomania of a more or less stable course. Our most current diagnostic guidelines for a hyperthymic
temperament consist of the following traits on a habitual basis since at least early adulthood: cheerful,
overoptimistic, or exuberant; extraverted and people-seeking, often to the point of being overinvolved or
meddlesome; overtalkative, eloquent, and jocular; uninhibited, stimulus-seeking, and sexually-driven;
vigorous, full of plans, improvident; overcon dent, self-assured, and boastful attitudes that may reach
grandiose proportions.
A systematic retrospective review of the case records of people with manic depression, whose course was
dominated by manic episodes, was recently undertaken in Munich, yielding attributes overlapping with our
proposed list: active, vivid, extraverted, verbally aggressive, self-assured, strong willed, engaged in self-
employed professions, risk-taking, sensation-seeking, breaking social norms, spendthrift, and generous.
The fact that at least 10 per cent of patients with major depression in an Italian study could be characterized
as premorbidly hyperthymic, suggests that this temperament has relevance to both major a ective poles.
This is an important diagnostic consideration, because rather than being considered narcissistic
depressions, these should be recognized as a soft bipolar variant.
Aetiological aspects
(55)
It is of interest that Gardner's ethological analysis of what constitutes ‘leadership’ led to a description
that overlaps with a hyperthymic pro le: cheerfulness, joking, irrepressible infectious quality, unusual
warmth, expansive, strong sense of con dence in one's abilities, scheming, robust, tireless, pushy, and

meddlesome. Hypothetically, this temperament evolved in primates whose social life required leadership to
better face challenges to the group from within and without.
(54)
In a sleep electroencephalography study, REM latency was found to be shortened; similar ndings have
been reported on the sleep of manic patients, thereby supporting the notion of a trait-state continuum at
the neurophysiological level. (Although counterintuitive, this neurophysiological marker appears to be
shared between the depressive and hyperthymic poles.) Finally, family history for frank bipolar disorder
characterizes many such individuals. The foregoing data, albeit limited, suggest that hyperthymic traits
share several key biological underpinnings of a ective disorder.
Course and treatment

Little is known about the natural course of the hyperthymic temperament, except what can be reconstructed
retrospectively from biographical and clinical studies. Given their overoptimistic and self-assured style of
thinking, these individuals feel perfectly t in all areas of functioning and thus have no need to consult a
psychiatrist. They do so only when forced by loved ones. There are no systematic treatment studies on
(50)
hyperthymia. Anecdotally, low doses of anticonvulsants such as valproate (e.g. 500–750 mg/day) can be
useful in reducing drivenness, when deemed appropriate on clinical grounds, such as in the presence of
cardiovascular disease, or when enormous sexual appetite places them at risk for social scandals and, in
(56)
some cases, exposure to HIV infection. Stimulant-abusing subjects with hyperthymia can be detoxi ed
with valproate, carbamazepine, or gabapentin. Clinically depressed subjects with a hyperthymic
temperament often respond poorly to antidepressants. In our opinion, the e cacy of lithium augmentation
in resistant depression is partly based on the high prevalence of hyperthymia in resistant populations; it
would be wise to keep the dose of lithium in augmentation in such individuals to a lower to middle range
(i.e. 600–900 mg/day).
People with hyperthymia are action-oriented, and are not inclined to any type of self-examination.
Furthermore, their hypertrophied sense of denial makes them poor candidates for psychotherapy. The
physician must, nonetheless, attempt psychoeducation about the harm that can come to them and their
loved ones because of their temperamental excesses. Alcohol consumption, which is common in these
individuals, should not be abruptly interrupted because of the risk of the switch to a suicidal depression. If
detoxi cation is necessary for health reasons, admission to a suitable inpatient facility should be arranged.
The occasion might be pro tably used for whatever counselling is deemed appropriate for life and health
situations confronting them at the time.
Therapeutic and preventive aspects
In clinical practice, hyperthymic individuals are likely to be confused with narcissistic or antisocial types.
Otherwise, they rarely present to psychiatrists, except as the premorbid adjustment of manic-depressive
illness. Hyperthymic individuals are often the driving force of society in economic and political life and
unless they are involved in scandals or suicidal behavior, rarely come to the attention of clinicians. In the
rare circumstances they seek psychiatric advice, it is due to exasperated pressure from loved ones; even
then, they tend to dictate rather than follow treatment recommendations. Their sense of entitlement

derives in part from the fact these individuals have considerable leadership talent and often bequeath large
sums of endowments for research, museums and other community projects. Some are performing artists.
Others are famed for their erotic life in the tabloid and popular press. Rare biological investigations have
(57,58)
been conducted on hyperthymia involving fascinating neurophysiologic and endophenotype studies.
The preventive potential of such investigations for manic-depressive illness remains uncertain at this time.
Further information
Akiskal, H.S., Akiskal, K.K. (eds.) (2005). TEMPS: Temperament Evaluation of Memphis, Pisa, Paris and San Diego. Special Issue,
Journal of A ective Disorders, 85, 1–242. 10.1016/j.jad.2004.12.003
WorldCat Crossref PubMed
References
1. Akiskal, H.S., Judd, L.L., Gillin, J.C., et al. (1997). Subthreshold depressions: clinical and polysomnographic validation of
dysthymic, residual and masked forms. Journal of A ective Disorders, 45, 53–63. 10.1016/S0165-0327(97)00059-1
WorldCat Crossref PubMed Web of Science
2. Meier, W., Lichterman, D., Minges, J., et al. (1992). The risk of minor depression in families of probands with major
depression: sex di erences and familiality. European Archives of Psychiatry and Clinical Neuroscience, 242, 89–
92. 10.1007/BF02191553

3. Kendler, K.S., Neale, M.C., and Kessler, R.C. (1992). A population-based twin study of major depression in women: the
impact of varying definitions of illness. Archives of General Psychiatry, 49, 257–66. 10.1001/archpsyc.1992.01820040009001
4. Akiskal, H.S., Bitar, A.H., Puzantian, V.R., et al. (1978). The nosological status of neurotic depression: a prospective three-to-
four year examination in light of the primary-secondary and unipolar-bipolar dichotomies. Archives of General Psychiatry, 35,
756–66. 10.1001/archpsyc.1978.01770300098011
5. Bronisch, T., Wittchen, H.-U., Krieg, C., et al. (1985). Depressive neurosis: a long-term prospective and retrospective follow-
up study of former inpatients. Acta Psychiatrica Scandinavica, 71, 237–48. 10.1111/j.1600-0447.1985.tb01280.x
6. Akiskal, H.S. and Cassano, G.B. (ed.) (1997). Dysthymia and the spectrum of chronic depressions. Guilford Press, New York.
Google Scholar Google Preview WorldCat COPAC
7. Akiskal, H.S., Akiskal, K.K., Lancrenon, S., et al. (2006). Validating the bipolar spectrum in the French National EPIDEP Study:
Overview of the phenomenology and relative prevalence of its clinical prototypes. Journal of A ective Disorders, 96, 197–
205. 10.1016/j.jad.2006.05.015
8. Akiskal, H.S. and Akiskal, K.K., (eds.) (2005). TEMPS: Temperament Evaluation of Memphis, Pisa, Paris and San Diego.
Special Issue, Journal of A ective Disorders, 50, 1–242. 10.1016/j.jad.2004.12.003
WorldCat Crossref
9. Akiskal, H.S. and Weise, R.E. (1992). The clinical spectrum of so-called ʻminorʼ depressions. American Journal of
Psychotherapy, 46, 9–22.
WorldCat PubMed Web of Science
10. Lewis, A. (1936). Melancholia: a prognostic study. Journal of Mental Science, 82, 488–558.
WorldCat
11. Akiskal, H.S. (1981). Suba ective disorders: dysthymic, cyclothymic and bipolar II disorders in the ʻborderlineʼ realm.
Psychiatric Clinics of North America, 4, 25–46.
WorldCat PubMed
12. Snaith, R.P. (1991). Measurement in psychiatry. British Journal of Psychiatry, 159, 78–82. 10.1192/bjp.159.1.78
13. Kendler, K.S., Neale, M.C., Kessler, R.C., et al. (1993). A longitudinal twin study of personality and major depression in
women. Archives of General Psychiatry, 50, 853–62.
14. Brieger, P. and Marneros, A. (1997). Dysthymia and cyclothymia: historical origins and contemporary development.
Journal of A ective Disorders, 45, 117–26. 10.1016/S0165-0327(97)00053-0
15. Akiskal, H.S. (1983). Dysthymic disorder: psychopathology of proposed chronic depressive subtypes. American Journal of
Psychiatry, 140, 11–20.
WorldCat PubMed
16. Placidi, G.F., Signoretta, S., Liguori, A., et al. (1998). The Semi-Structured A ective Temperament Interview (TEMPS-I):
reliability and psychometric properties in 1010 14–26 year students. Journal of A ective Disorders, 47, 1–10. 10.1016/S0165-

0327(97)00122-5
17. Kasahara, Y. (1991). The practical diagnosis of depression in Japan. In The diagnosis of depression (eds. J.P. Feighner and
W.F. Boyer), pp. 163–75. Wiley, Chichester.
18. Montassut, M. (1938). La dépression constitutionnelle: l'ancienne neurasthénie dans ses rapports avec la médecine générale;
clinique biologie, thérapeutique. Masson, Paris.
19. Akiskal, H.S. (1996). Dysthymia as a temperamental variant of a ective disorder. European Psychiatry, 11 (Supplement),
117s–22s. 10.1016/0924-9338(96)85185-6
WorldCat Crossref Web of Science
20. Akiskal, H.S. (2001). Dysthymia and cyclothymia in psychiatric practice a century a er Kraepelin. Journal of A ective
Disorders, 62, 17–31. 10.1016/S0165-0327(00)00347-5
21. The WPA Dysthymia Working Group (1995). Dysthymia in clinical practice. British Journal of Psychiatry, 166, 174–
83. 10.1192/bjp.166.2.174
WorldCat Crossref
22. Licinio, J., Prilpko, I., and Bolis, C.L. (eds.) (1997). Dysthymia in neurological disorders. In Proceedings of the WHO Meeting.
World Health Organization, Geneva.
23. Akiskal, K., Akiskal, H.S. (2005). The theoretical underpinnings of a ective temperaments: implications for evolutionary
foundations of bipolarity and human nature. Journal of A ective Disorders, 85, 231–9. 10.1016/j.jad.2004.08.002
24. Markianos, M., Tripodianakis, J., Sarantidis, D., et al. (2006). Plasma testosterone and dehydroepiandrosterone sulfate in
male and female patients with dysthymic disorder. Journal of A ective Disorders, 101, 255–8. 10.1016/j.jad.2006.11.013
WorldCat Crossref
25. Brambilla, F., Monteleone, P., Maj, M. (2004). Interleukin-1beta and tumor necrosis factor-alpha in children with major
depressive disorder or dysthymia. Journal of A ective Disorders, 78, 273–7. 10.1016/S0165-0327(02)00315-4
26. Field, T., Diego, M.A., Hernandez-Reif, M., et al. (2008). Prenatal dysthymia versus major depression e ects on maternal
cortisol and fetal growth. Depressive Anxiety, 22, in press.
WorldCat
27. Lyoo, I.K., Kwon, J.S., Lee, S.J., et al. (2002). Decrease in genus of the corpus callosum in medication-Naïve, early-onset
dysthymia and depressive personality disorder. Biological Psychiatry, 52, 1134–43. 10.1016/S0006-3223(02)01436-1
28. Tebartz van Elst, L., Woermann, F.G., Lemieus, L., et al. (1999). Amygdala enlargement in dysthymia—a volumetric study of
patients with temporal lobe epilepsy. Biological Psychiatry, 46, 1614–23. 10.1016/S0006-3223(99)00212-7
29. Oliveira, J.R., Carvalho, D.R., Pontual, D., et al. (2000). Analysis of the serotonin transporter polymorphism (5-HTTLPR) in
Brazilian patients a ected by dysthymia, major depression and bipolar disorder. Molecular Psychiatry, 5, 348–
9. 10.1038/sj.mp.4000725
30. Gonda, X., Zsombok, T., Rihmer, Z., et al. (2006). The 5HTTLPR polymorphism of the serotonin transporter gene is

associated with a ective temperaments as measured by TEMPS-A. Journal of A ective Disorders, 91, 125–
31. 10.1016/j.jad.2005.12.048
31. Burton, S.W. and Akiskal, H.S. (ed.) (1993). Dysthymic disorder. Gaskell and Royal College of Psychiatrists, London.
32. Kraemer, P.D. (1993). Listening to Prozac. Viking Press, New York.
33. Randlov, C., Mehlsen, J., Thomsen, C.F., et al. (2006). The e icacy of St. John's Wort in patients with minor depressive
symptoms or dysthymia—a double-blind placebo-controlled study. Phytomedicine, 13, 215–21. 10.1016/j.phymed.2005.11.006
34. Niculescu, A.B., Akiskal, H.S. (2001). Proposed endophenotypes of dysthymia: evolutionary, clinical and
pharmacogenomic considerations. Molecular Psychiatry, 6, 363–6. 10.1038/sj.mp.4000906
35. Koukopoulos, A. (2003). Ewald Hecker's description of cyclothymia as a cyclical mood disorder: its relevance to the
modern concept of bipolar II. Journal of A ective Disorders, 73, 199–205. 10.1016/S0165-0327(02)00326-9
36. Akiskal, H.S., Djenderedjian, A.H., Rosenthal, R.H., et al. (1977). Cyclothymic disorder: validating criteria for inclusion in the
bipolar a ective group. American Journal of Psychiatry, 134, 1227–33.
37. Akiskal, H.S., Khani, M.K., and Scott-Strauss, A. (1979). Cyclothymic temperamental disorders. Psychiatric Clinics of North
America, 2, 527–54.
WorldCat
38. Akiskal, H.S. (1992). Delineating irritable-choleric and hyperthymic temperaments as variants of cyclothymia. Journal of
Personality Disorders, 6, 326–42. 10.1521/pedi.1992.6.4.326
WorldCat Crossref
39. Maremmani I, Perugi G, Pacini M, et al. (2007). Toward a unitary perspective on the bipolar spectrum and substance abuse:
opiate addiction as a paradigm. Journal of A ective Disorders, 93, 1–12. 10.1016/j.jad.2006.02.022
WorldCat Crossref
40. Merikangas, K.R., Herrell, R., Swendsen, J., et al. (2008). Specificity of bipolar spectrum conditions in the comorbidity of
mood and substance use disorders: results from the Zurich cohort study Archives of General Psychiatry, 65, 47–
52. 10.1001/archgenpsychiatry.2007.18
41. Akiskal, H.S. and Akiskal, K. (1988). Re-assessing the prevalence of bipolar disorders: Clinical significance and artistic
creativity. [Psychiatric et Psychologic] European Psychiatry, 3, 29s–36s.
WorldCat
42. Akiskal, H.S., Downs, J., Jordan, P., et al. (1985). A ective disorders in the referred children and younger siblings of manic-
depressives: Mode of onset and prospective course. Archives of General Psychiatry, 42, 996–
1003. 10.1001/archpsyc.1985.01790330076009
43. Kochman, F.J., Hantouche, E.G., Ferrari, P., et al. (2005). Cyclothymic temperament as a prospective predictor of bipolarity
and suicidality in children and adolescents with major depressive disorder. Journal of A ective Disorders, 85, 181–
9. 10.1016/j.jad.2003.09.009

44. Akiskal H.S., Akiskal, K.K. (2007) In search of Aristotle. Journal of A ective Disorders, 100, 1–6. 10.1016/j.jad.2007.04.013
45. Evans, L., Akiskal, H.S., Greenwood, T.A., et al. (2008). Suggestive linkage of a chromosomal locus on 18p11 to cyclothymic
temperament in bipolar disorder families. American Journal of Medical Genetics B Neuropsychiatric Genetics, in press.
46. Perugi, G., Toni, C., Passino, M.C., et al. (2006). Bulimia nervosa in atypical depression: the mediating role of cyclothymic
temperament. Journal of A ective Disorders, 82, 91–7. 10.1016/j.jad.2005.12.038
WorldCat Crossref Web of Science
47. Akiskal, H.S., Akiskal, K.K., Perugi, G., et al. (2006). Bipolar II and anxious reactive ʻcomorbidityʼ: toward better phenotypic
characterization suitable for genotyping. Journal of A ective Disorders, 96, 239–47. 10.1016/j.jad.2006.08.010
48. Hantouche, E.G., Angst, J., Demonfaucon, et al. (2003). Cyclothymic OCD: a distinct form? Journal of A ective Disorders,
75, 1–10. 10.1016/S0165-0327(02)00461-5
49. Perugi, G., Toni, C., Travierso, M.C., et al. (2003). The role of cyclothymia in atypical depression: toward a data-based
reconceptualization of the borderline-bipolar II connection. Journal of A ective Disorders, 73, 87–98. 10.1016/S0165-
0327(02)00329-4
50. Akiskl, H.S. (1977). Chronic disturbances of temperament. Bibliotheca Psychiatrica (Basel), 167, 29–32.
WorldCat
51. Karam, E.G., Mneimneh, Z., Salamoun, M., et al. (2005). Psychometric properties of the Lebanese-Arabic TEMPS-A: a
national epidemiologic study. Journal of A ective Disorders, 87, 169–183. 10.1016/j.jad.2005.02.010
52. Vázquez, G.H., Nasetta, S., Mercado, B., et al. (2007). Validation of the Temps-A Buenos Aires: Spanish psychometric
validation of a ective temperaments in a population study of Argentina. Journal of A ective Disorders, 100, 23–
9. 10.1016/j.jad.2006.11.028
53. Rózsa, S., Rihmer, Z., Gonda, X., et al. (2007). A study of a ective temperaments in Hungary: Internal consistency and
concurrent validity of the TEMPS-A against the TCI and NEO PI-R. Journal of A ective Disorders, in press.
WorldCat
54. Akiskal, H. (1984). Characterologic manifestations of a ective disorders: toward a new conceptualization. Integrative
Psychiatry, 2, 83–8.
WorldCat
55. Gardner, R. Jr. (1982). Mechanisms in manic-depressive disorder: an evolutionary model. Archives of General Psychiatry,
39, 1436–41. 10.1001/archpsyc.1982.04290120066013
56. Moore, D., Atkinson, J.H., Gonzalez, B.A., et al. (2005). Temperament and risky behaviors: A pathway to HIV? Journal of
A ective Disorders, 85, 191–200. 10.1016/S0165-0327(03)00193-9
57. Hensch, T., Herold, U., Brocke, B. (2007). An electrophysiological endophenotype of hypomanic and hyperthymic
personality. Journal of A ective Disorders, 101, 13–26. 10.1016/j.jad.2006.11.018

58. Chiaroni, P., Hantouche, E.G., Gouvernet, et al. (2004). [Hyperthymic and depressive temperaments study in controls, as a
function of their familial loading for mood disorders.] Encephale, 30, 509–15. 10.1016/S0013-7006(04)95464-4
Notes
* Unless otherwise specified, in the remainder of this chapter, references to concepts, historical developments, and
research covering dysthymia and cyclothymia through the year 2000 can be found in this centenary review of Kraepelinian
(20)
psychiatry.
* Unless otherwise specified, this review article contains most of the references to the concepts, history, and research on
the hyperthymic type.
© Oxford University Press

4.5.9 Dysthymia, Cyclothymia, and Hyperthymia: Hagop S. Akiskal

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New Oxford Textbook of Psychiatry (2 edn)

Michael Gelder (ed.) et al.

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https://doi.org/10.1093/med/9780199696758.003.0091 Pages 681–692

Subthreshold a ective conditions, personality, and temperament

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The dysthymic spectrum

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Clinical picture and diagnostic considerations(20)*

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Long-standing subthreshold depression of a fluctuating or persistent nature

Gloomy and joyless disposition

Brooding about the past and guilt prone

Low drive and lethargy

Low self-esteem and preoccupation with failure

Identifies su ering as part of the habitual self

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As for neuroendocrine markers, thyroid-releasing hormone- thyroid-stimulating hormone challenge and

Familial a ective loading

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Diurnality of inertia, gloominess, and anhedonia

Thyroid-releasing hormone-thyroid-stimulating hormone challenge test abnormalities

Lowered interlukin-1-beta production

s-allele in serotonin transporter gene

Prospective course complicated by recurrent major depressive episodes

Positive response to selected thymoleptics

Table 4.5.9.3 Major controlled pharmacological trials in dysthymia worldwide*

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Vallejo et al. (1987) Spain Phenelzine versus imipramine

Kocsis et al. (1987) USA Imipramine versus placebo

Stewart et al. (1989) USA Phenelzine versus placebo

Thase et al. (1996) USA Sertraline versus imipramine

Vanelle et al. (1998) France Fluoxetine versus placebo

Lecrubier et al. (1996) France Amisulpride versus placebo

Versiani et al. (1997) Brazil Moclobemide versus imipramine

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Provide a believable dose of optimism

Optimize compliance to pharmacotherapy

Limit destructive expression of negative feelings

Address accumulated conflicts

Combat postdepressive resignation and inertia

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Be aware of countertransference feelings

Consult experts with extensive experience in treating chronic depression

Gradually mobilize patient's skills and resources

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Cyclothymic disorder and labile-irritable variants(20)

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Table 4.5.9.5 Discriminatory biphasic characteristics of cyclothymic disorder*

Lethargy alternating with eutonia

Shaky self-esteem alternating between low self-confidence and overconfidence

Decreased verbal output alternating with talkativeness

Mental confusion alternating with sharpened thinking

Introverted self-absorption alternating with uninhibited people-seeking

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Reference Population (Country) Rate (%)

Akiskal et al. (1977) Mental health centre (USA) 10