A 22-Year-Old Female College Athlete With Wild Mood Swings

Claudia L. Reardon, MD


June 17, 2022


Cyclothymic disorder is a lifelong fluctuating mood disorder on the bipolar spectrum that involves recurrent episodes of hypomanic symptoms and recurrent episodes of depressive symptoms. Importantly, these episodes fall short of meeting the full criteria for hypomanic or manic episodes and major depressive episodes. Thus, cyclothymic disorder is often viewed as a milder form of bipolar disorder in some respects. It has these specific diagnostic criteria[1]:

  1. For at least 2 years (at least 1 year in children and adolescents), there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.

  2. During the above 2-year period (1 year in children and adolescents), criterion A symptoms have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.

  3. Criteria for a major depressive, manic, or hypomanic episode have never been met.

  4. The symptoms in criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

  5. The symptoms are not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition (eg, hyperthyroidism).

  6. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

This patient appears to have episodes of hypomanic symptoms that last 2-3 days. They do not meet the criteria for full hypomanic episodes, which by definition must last at least 4 days. Thus, bipolar II disorder, which involves full hypomanic episodes as well as major depressive episodes, is ruled out. She also appears to have episodes of depressive symptoms that last 3-5 days. They do not meet the criteria for full major depressive episodes, which by definition must last at least 2 weeks. This further excludes bipolar II disorder, which requires full major depressive episodes. The duration of the "ups" and "downs" is the key in terms of differential diagnoses.

Because the patient does not have full hypomanic episodes, she does not meet the criteria for full manic episodes, which last even longer (typically 1 week or more) and cause significant dysfunction. Without ever having had a full manic episode, she does not qualify for a diagnosis of bipolar I disorder, which by definition requires a history of at least one manic episode.

Although some patients, including the one in this case, may function particularly well during some or all of the periods of hypomanic symptoms, over the prolonged course of cyclothymic disorder, the diagnostic criteria require the presence of clinically significant distress or impairment in functioning because of mood symptoms. The unpredictable and inconsistent nature of the symptoms tends to be a common source of distress or dysfunction. Interpersonal relationships and school and/or job performance can and often do suffer.


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