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Dr. Ivan Goldberg, Psychopharmacologist

Q:  What is the difference between a mixed episode and rapid cycling??

A: A mixed episode is a mood state in which an individual shows some symptoms characteristic of mania together with other symptoms found in depression, such as depressed mood, inability to experience pleasure, guilt, suicidal thinking or anxiety. For example, an individual may have the racing thoughts characteristic of mania, but the content of the racing thoughts may be related to themes of guilt, pessimism, or suicide. The presence of a history of past suicide attempts and substance abuse increases the likelihood that someone in a mixed state will experience suicidal ideation.

People with mixed states are at increased risk for substance abuse and suicide attempts when compared to people with purely manic episodes. It has been estimated that over a lifetime, 40 percent of individuals with bipolar disorder will experience a mixed episode. 

Rapid cycling is a form of bipolar disorder in which there are four or more distinct episodes within a 12-month period. The episodes must either be separated by two months of wellness or by a switch in polarity. Rapid cycling occurs at some point in almost three quarters of women with bipolar disorder and in about a quarter of men with the disorder. 

Some people experience ultrafast rapid cycling or ultradian cycling in which they cycle within a single day. Antidepressant use and undetected hypothyroidism are frequent causes of rapid cycling. 

Dr. Joe Nieder, Pediatric Psychiatrist

Q. My wife has cyclothymia and is being successfully treated with a mood stabilizer. We have teenage children-- a son and a daughter. What are the chance that they too might have cyclothymia or other mood disorders?

A. Your son and daughter would be at increased risk for a mood disorder, because like many medical conditions, mood disorders tend to run in families. This tendency of occurring in biologic relatives is seen with lots of conditions including heart disease, allergies, and asthma. However, just because there could be a genetic component, that does not mean that the condition will occur in all offspring, or even in a major proportion of the children who have a parent with the condition. It simply means that the chance of developing a cyclothymia or another mood disorder would be somewhat greater than in a family with no history of mood disorders. 

Early symptoms of cyclothymia in a teenager might include sleep problems, anger, irritability, declining school performance, difficulties with friends and peers, major conflicts with parents or siblings. This is a difficult diagnosis to make because we see many of these symptoms in teenagers without mood problems.

In the child with a mood disorder, though, the symptoms would be exaggerated and more severe than in the typical teenager. One might also see more clearly defined episodes of depression or mood swings, or even suicidal ideas or acts. In addition, there is an increased risk of substance abuse, with alcohol and marijuana being the most common. In boys there is a greater incidence of aggressive or violent behavior; in girls, more mood instability or self-destructive ideas or acts. 

With a history of cyclothymia in a parent, one would look for any symptoms that suggest an illness in a teenager, especially in early to mid-adolescence. If possible , antidepressants would be avoided as they could increase mood cycling.

By Michael Craig Miller, MD

The Austrian-Jewish philosopher Martin Buber once wrote, “Every person born into this world represents something new, something that never existed before, something original and unique.” This attractive sentiment seems to make the notion of a personality diagnosis pointless. Why typecast people, if everyone is different? 

Individualists are especially troubled by a cookbook approach to codifying personality and many mental health professionals believe that’s what the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) does. In its third edition, published in 1980, that volume introduced diagnostic criteria for all psychiatric disorders. It provided researchers and clinicians with reliable definitions to replace the previously vague descriptions. 

The DSM system favors categories (like subtypes of depression or schizophrenia) over dimensions of illness (such as the intensity of sadness or the degree of isolation a person feels). Symptoms can be found in multiple categories, and a person may end up carrying multiple diagnoses. Of course, there are no sharp divisions between any of the mental disorders, but personality disorders are hardest to reduce to a defining checklist. Many researchers have therefore advocated a dimensional approach to diagnosing personality disorders, focusing on the extent to which various traits are expressed and abandoning categories altogether. 

In practice, clinicians don’t necessarily think about categories or dimensions of illness, nor do they dwell on distinct traits and behaviors. Rather, they try to understand a complete picture — that is, what comprises an individual’s development, experiences, aspirations, and ways of relating to others. Now researchers are considering new ways to diagnose personality disorders that they hope will add subtlety and complexity to established definitions.

One of the most interesting proposals is a suggestion that clinicians compare their patients to composite descriptions called prototypes that are developed from questionnaires answered by experienced clinicians [Westen D, et al., American Journal of Psychiatry, May 2006]. In one set of questionnaires, clinicians described the features they thought were typical of various personality disorders. In another set of questionnaires, they described actual patients. Researchers developed prototypes from this set by determining statistically which personality traits tended to go together. The resulting prototype descriptions, each about a paragraph long, included much more information than current DSM definitions.

The results were encouraging. The diagnoses based on prototypes were at least as good as the current system for predicting a person’s functioning and guiding decisions about treatment. Patients were less likely to be given comorbid (multiple or redundant) diagnoses. And clinicians preferred the prototype method. They found it more meaningful and easier to use than a checklist of criteria, partly because it corresponded more closely to what many, if not most, of them were already doing in practice.

Although this new system still needs refinement, it looks promising. With its help, clinicians can quickly develop a broader picture of a patient’s or client’s problems. They can also determine when a patient fits none of the prototypes and therefore may require blended approaches to treatment. 

Clinicians and researchers alike might embrace such a system, because they know that a diagnosis of personality disorder is only a starting point. At best, it provides a framework for doing what Martin Buber’s saying implies is necessary — understanding what is original and unique about a person who has asked for help. 

Michael Craig Miller, M.D. is editor- in-chief of the Harvard Mental Health Letter. This article originally appeared in the August 2006 issue.

© 2006 President and Fellows Harvard College Reprinted with permission. www.health.harvard.edu/newsletters/Harvard_Mental_Health_Letter.htm Want even more news about mental health? Consider the Harvard Mental Health Letter, an excellent monthly newsletter covering the latest in psychology and psychiatry. MOODS readers can also take advantage of a special introductory rate of only $29 per year (rather than the usual $72). To take advantage of the offer, call 877-649-9457. Make sure to mention that you would like to subscribe for the special MDSG member rate of $29.

Does it sometimes seem that our most energetic, productive people are actually hypomanic? Dr. Ronald Fieve, a leader in the field of bipolar disorder, has just published Bipolar II, the first major book on this elusive, often misdiagnosed bipolar subtype. 

Decades ago Dr. Fieve was one of the pioneers in using lithium to treat biopolar disorder, but he is best-known for his 1975 book Moodswing, the landmark volume on bipolar disorder that first helped the general public to understand mood disorders. My sister, like so many family members who seek insight into this illness, read Moodswing and it helped her grasp what was going on with me. 

In his latest work, Fieve delves into bipolar II, a subtype that’s much less known and is often described as a milder form of the disease. The main difference between I and II is the intensity of the high phases. In contrast to bipolar I’s, in which mania tends to take the form of explosive highs, distorted and dangerous thoughts and, selfdestructive behavior, bipolar IIs experience hypomania, which is often a period of exuberant mood, creative thoughts, and increased productivity. (According to Fieve, about half of bipolar II's experience these sorts of “beneficial highs” whereas the other half will have a lot of irritability.) 

As Fieve explains, mood disordered people tend to seek out a psychiatrist when they are depressed, not when they are manic or hypomanic. Therefore, when he takes a case history, he asks about happier times in order to gain insight into possible periods of mania. He also looks into a patient’s family history for clues: alcoholism, antisocial behavior, remarkable accomplishments, drug addiction, and mood disorders. Fieve includes several vignettes to illustrate his theme and describes patients who, with the right diagnosis and treatment, are able to avoid debilitating depression and experience some periods of beneficial hypomania. He also includes a chapter on proper diagnosis and treatment. 

All of this helps to lay the groundwork for a deeper understanding of bipolar II, and his examples do shed light on how, in certain patients, hypomania has it’s pluses. However, there is still that central philosophical question many of us with mood disorders have: Do we have to give up all the benefits of our highs to have a positive outcome? Fieve opens up an important discussion about the nature of this complex illness. 

In our last issue, we asked you to come up with television titles that spoofed existing shows and used mood disorders as a theme. And the winners are...

First Prize:
  The O.C.D.   - Abbe Jo Phillips

Second Prize: 
  Two and a Half Ativan  - Eileen Budd

Third Prize: 
  The Symptoms  - Barbara Staehle

Honorable Mention: 
  Depressed Housewives  - Jason Petree
  Unhappy Days  - Trish Blodget
  Dancing with the Buspars  - Eileen Budd
  Top Shrink  - Ellisa Hamm
  Let’s Make a Diagnosis  - Joe Piscopia
  Da MDSG Show  - Nathan Hirsch 

Thanks to everyone who entered! 
  

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