Cyclothymia, the Quintessential Mood Temperament: Ignored or Forgotten? Part I: An Overview

Actually, it is both. Mood temperaments have been described from antiquity. Our Greek colleagues remind us that, prior to Aretaeus of Cappadocia (circa 140 CE), the concept of temperament was espoused by Polybus, a pupil of Hippocrates (400 BC) and the school of Cos.¹

More recently, Rovai, et al, indicate that Kraepelin and Kretschmer hypothesized a continuum between full-blown affective pathology and premorbid temperaments, referring to them as lifelong, early-onset, attenuated, subclinical forms of manic-depressive psychosis.²

But in spite of more modern research over the past 4 decades by Akiskal, Perugi, Hantouche, Zoltan, Gonda, Rihmer, Rovai, and others, covering nearly every continent, as well as the classical descriptions of mood temperaments starting with the term cyclothymia (coined in 1892 by Karl Kahlbaum³), and Kraepelin’s delineation of depressive, manic, cyclothymic, and irritable temperaments, you will have difficulty finding discussions of these temperaments in current textbooks of psychiatry. The notable exceptions to this are Ghaemi,⁴ Goodwin and Jamison,⁵ and Akiskal.⁶

Cyclothymia was mentioned in a 1914 Boston Medical and Surgical Journal (precursor to The New England Journal of Medicine) discussing early concepts of “psychoneurotics, neuropathic constitution, and personality,” indicating the psychoanalytic influence that accompanied these concepts as they crossed the Atlantic.⁷

Kraepelin’s theoretical framework regarding dysthymic and cyclothymic dispositions both as clinically relevant extreme forms of temperament and as precursors of major affective episodes was reviewed by Akiskal in the extensive literature on familial and prospective course findings in favor of a new paradigm of continuum between subthreshold—seemingly characterological—and major and/or endogenous depressions.⁸

These psychiatrists and researchers advocate a transition or spectrum of familial mood temperaments from mild to increasing severity, extending the personality concepts of Eysenck and Cloninger to a diathesis for clinical mood disorders, placing mood temperaments firmly in a medical model.

Although rarely used or taught in training programs, cyclothymia has been retained in various forms as cyclothymic personality in DSM-I (1952) and II (1968) to cyclothymic disorder in DSM-III (1980) to the current DSM-5. It has never described mood temperament in any DSM (Table 1^6,9,10,4).

Akiskal indicates that terms like neurotic, psychopathic and personality disorder are usually used in a pejorative context, whereas “the concept of temperament is referring to the optimum mixture or both liabilities and assets regarding a human being.”⁶ In many of his writings, he also describes the adaptive, artistic, and evolutionary benefits of the classic mood temperaments of hyperthymia, cyclothymia, and dysthymia.

The mood temperaments are considered to be precursors of major mood disorders(ie, forme fruste, or the atypical or attenuated manifestation of a disease or syndrome). The mood temperaments can be present prior to the onset of an episodic mood illness and continue between remitted mood episodes, and they are inextricably intertwined with personality traits, as defined by Eysenck and Cloninger.

Cyclothymia Mood Temperament Proper

Contrary to DSM definition, based on the recurrence of low-grade episodes, cyclothymia is better defined as an exaggeration of cyclothymic temperament: early onset, complex temperament structure, high mood instability and reactivity, and rapid switching¹¹ (Table 2^12,13).

Of all the mood temperaments—hyperthymic, cyclothymic, dysthymic, irritable, and anxious—individuals with the cyclothymic mood temperament are the most likely to be admitted to a psychiatric facility and to have suicidal ideations and attempts, a history of instability in relationships and employment, and relatives with either mild or severe affective disorders.

Previous clinical follow-up investigations as well as familial—genetic, biological, and treatment—response studies in clinical populations have demonstrated that there is a continuum between cyclothymic disorder and bipolars I and II disorders and between subsyndromal depression, minor depression/dysthymia and unipolar major depression, indicating that patients with milder forms of mood disorders have a very high risk of developing its more severe forms.¹⁴

Prevalence of Mood Temperaments and Cyclothymia

Prevalence varies according to source and definition. Predominant affective temperaments are present in up to 20% of the healthy general population, but in relatives of individuals with mood illnesses, about 50% have a mood temperament.⁹ Cyclothymia is a common temperamental variant occurring in 0.4% to 6.3% of the population.⁵ However, according to Angst¹⁴:

“Most healthy people report depressive and hypomanic symptoms, and many are identifiable as manifesting depressive, hypomanic, and cyclothymic temperaments, which appear to predispose to the respective affective disorders and personality disorders. Only about 15% of the population report no such symptom over their lifetime and are ‘super-normal,’ with very low scores for vegetative lability and neuroticism.”

According to Ghaemi, if a 50% threshold is used on the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego (TEMPS-A) self-administered questionnaire (rather than the standard 75%) about 80% of individuals with mood disorders have a probable mood temperament⁴ (Table 3¹¹).

Validation

Over the past quarter-century, the TEMPS-A questionnaire has been validated in dozens of languages and in many countries, including Egypt, Japan, Lebanon, Portugal, Italy, Germany, France, China, Korea, Russia, Tunis, Argentina Brazil, Armenia, Hungary, and the United States. A PubMed search for TEMPS-A reveals more than 300 articles in diverse psychiatric and medical settings to evaluate mood temperaments.^15,16

Part II of this series will address cyclothymia in children and suicidal risk, and Part III will address differentiation between cyclothymia and borderline personality and treatment.

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

References

1. Koufaki I, Polizoidou V, Fountoulakis KN. Psychiatriki. 2017;28(2):142-155.

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

3. Baethge C, Salvatore P, Baldessarini RJ. Cyclothymia, a circular mood disorder. Hist Psychiatry. 2003;14(55 Pt 3):377-399.

4. Ghaemi SN. Clinical Psychopharmacology: Principles and Practice. Oxford University Press; 2019.

5. Goodwin FK, Redfield Jamison K. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition. Oxford University Press; 2007.

6. Gelder M, Andreasen N, Lopez-Ibor J, Geddes J. New Oxford Textbook of Psychiatry, 2nd Edition. Oxford University Press; 2012.

7. Clark LP. Some personal results in psychoanalysis and the future of psychotherapy. Boston Med Surg J. 1914;170:903-907.

8. Akiskal HS. Dysthymia and cyclothymia in psychiatric practice a century after Kraepelin. J Affect Disord. 2001;62(1-2):17-31.

9. Gonda X, Vazquez GH. Theoretical and clinical overview of affective temperaments in mood disorders. Psicodebate. 2014;14(2): 39-58.

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

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

12. Akiskal HS, Placidi GF, Maremmani I, et al. TEMPS-I: delineating the most discriminant traits of the cyclothymic, depressive, hyperthymic and irritable temperaments in a nonpatient population. J Affect Disord. 1998;51(1):7-19.

13. Akiskal HS, Djenderedjian AM, Rosenthal RH, Khani MK. Cyclothymic disorder: validating criteria for inclusion in the bipolar affective group. Am J Psychiatry. 1977;134(11):1227-1233.

14. Angst J. The bipolar spectrum. Br J Psychiatry. 2007;190:189-191.

15. Akiskal HS, Mendlowicz MV, Jean-Louis G, et al. TEMPS-A: validation of a short version of a self-rated instrument designed to measure variations in temperament. J Affect Disord. 2005;85(1-2):45-52.

16. Vöhringer PA, Whitham EA, Thommi SB, et al. Affective temperaments in clinical practice: a validation study in mood disorders. J Affect Disord. 2012;136(3):577-580.