A Case of Bipolar Affective Disorder Not Otherwise Specified Or Cyclothymia

Case report A case of bipolar affective disorder not otherwise specified or cyclothymia BR Adhikari, N Sapkota, R Gautam, M Basnet, P Koirala, N Rajbhandari Department of Psychiatry, BP Koirala Institute of Health Sciences, Dharan, Nepal

Abstract The symptoms of mood disorders can be highly variable from person to person, and there are some differences in the present systems of classification to view some of the presentations of Bipolar Disorder Not Otherwise Specified (BPAD-NOS) and cyclothymia. This case highlights one of such presentations. Keywords: bipolar disorder not otherwise specified, cyclothymia, classification system Introduction BPAD-NOS is diagnosed ‘if patients exhibit He gives history of being diagnosed with depressive and manic symptoms as the major pulmonary tuberculosis (PTB) four years ago. features of their disorder and do not meet the After being diagnosed with PTB, he could not diagnostic criteria for any other mood disorder sleep the whole night being preoccupied with or other DSM-IV mental disorders’. It has the negative thoughts (e.g. not be able to fulfill been cautioned to be used rarely and some his dreams due to illness) and woke up with the of the examples given in DSM-IV are: very feeling of heaviness in body and uneasiness about rapid alternation (over days) between manic himself. He experienced sadness throughout symptoms and depressive symptoms that meet the days, weakness, and easy fatigability. He symptom threshold criteria but not minimal lost interest and joy in interacting with family duration criteria for manic, hypomanic, or major members, relatives, and friends he normally depressive episodes; or situations in which the used to have in such interactions. Together with clinician has concluded that a bipolar disorder irritability, decreased food intake, concentration is present but is unable to determine whether it difficulties, decreased confidence, he felt is primary, due to general medical condition, or worthlessness, hopelessness, and that it would substance induced.1 be better if he were dead. A couple of times, thoughts of just leaving the family came to him, Essential feature of cyclothymia is a persistent nevertheless, worries about them prevented instability of mood involving periods of mild him from doing so. There was no guilt, suicidal depression and mild elation, but not severe ideas or history of substance abuse. This episode or prolonged enough to fulfill the criteria for lasted for 6-7 days immediately followed by bipolar affective disorder or recurrent depressive increased sense of well-being, increased energy disorder.2 level, feeling happy most of the time, increased Case Report confidence, increased sociability and helping A 20-year-old, married, male with mild others in their work, and sleeping less than usual obsessive-compulsive trait presented in the (and still feeling fresh) for the next 2-3 days. Psychiatry Out-Patient-Department. There was no history suggestive of boastfulness Address for correspondence or grandiosity, reckless behavior and delusions Dr. Baikuntha Raj Adhikari or hallucinations. By the third day of such Assistant Professor Department of Psychiatry, BPKIHS elevation, symptoms subsided. Email: [email protected]

221 Adhikari et al A case of bipolar affective disorder not otherwise specified or cyclothymia Health Renaissance 2014;12(3): 221-223

Second such cycle happened after 4 months of Patients with cyclothymia are aware of mood first episode. Thereafter, it happened 10-14 times swings, distressed by it, and usually seek help in last 4 years. He did not remember exactly during depressive phase.4 These mood swings the course; however, on leading question, there are biphasic (e.g. eutonia versus anergic was remission for 2 months in between and periods, people-seeking versus self-absorption); such cycles occurred less than 4 times a year. and that most patients with cyclothymia and His anti-tubercular treatment was completed in bipolar disorder II patients report a threshold one year. There was no or only minimal socio- of 1-3 days (on occasion one week or longer) occupational dysfunction, and no family history for elevation of mood which makes the 4 days of mental illness. threshold for hypomania too conservative in His systemic examination and mental state official diagnostic manuals. examination were normal. He had come to Our patient presented with alternation of consult for distress he had in low phases. There depressive symptoms for about a week followed was only minimal or no dysfunction during by elevation of mood for 2-3 days, being short both phases so far. Family members were not of duration criteria for both a depressive episode available to corroborate the history. (2 weeks) and a hypomanic episode (4 days); however, fulfilling the symptoms threshold Discussion criteria for cyclothymia, mild depressive The essential feature of hypomania is ‘a episode, and hypomania. Given that he has persistent mild elevation of mood, increased more than 2 years of disorder with instability of energy and activity, usually marked feelings mood with mild depression or elation, duration of well-being, and both physical and mental less than for depressive episode or hypomania, efficiency. Increased sociability, talkativeness, without major dysfunction, symptoms with or over familiarity, increased sexual energy, and without intervening periods of normal mood, a decreased need for sleep are often present cyclothymia looks likely as per ICD-10 (DCR). but not to the extent that they lead to severe Or it can also be argued against cyclothymia in disruption of work or result in social rejection’2. 3 that DSM-IV requires that there be no remission ICD-10 (DCR) requires 4 days duration. of more than 2 months at a time. Given that some ICD-10 mentions in diagnostic guidelines of depressive patients may report their euthymic cyclothymia ‘a persistent instability of mood period as ‘high period’4 and patient fulfilling involving periods of mild depression and mild symptoms threshold criteria for depression with elation, but not fulfilling criteria for bipolar less than 2 weeks’ duration, one might also affective disorder or recurrent depressive consider recurrent brief depressive disorder. If disorder (including hypomania and mild one cycle be considered two episodes, one may depression) as an essential feature’.3 DSV-IV wonder about the rapid cycling as well. requires remission period less than 2 months at a time.1 ICD-10 (DCR) mentions ‘at least Conclusion 2 years of instability of mood…… with or The authors consider the case as a case of without intervening periods of normal mood’ BPAD-NOS for fulfilling symptom threshold for symptom free interval and ‘none of the criteria for depressive episode and hypomania manifestations of depression or hypomania but not for the duration criteria, and remission during such two year period should be period of more than 2 months in the absence sufficiently severe or long standing to meet of known organic disorder or a substance use criteria for manic episode or depressive episode’ disorder. 3

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References 1. American Psychiatric Association. 3. World Health Organization. The ICD-10 Diagnostic and Statistical Manual of Classification of Mental and Behavioural Mental Disorders. 4th ed-Text Revision. Disorders—Diagnostic Criteria for Washington, DC: American Psychiatric Research. Geneva: WHO; 1993. Association; 2000. 4. Akiskal, H.S. Dysthymia, cyclothymia, and 2. World Health Organization. The ICD-10 hyperthymia. In: Gelder MG, Andreasen Classification of Mental and Behavioural NC, Lopez-Ibor J, Geddes RJ, editors. New Disorders—Clinical Descriptions and Oxford Textbook of Psychiatry. 2nd ed.- Diagnostic Guidelines. Geneva: WHO; Indian Edition. Oxford University Press; 1992. 2011.

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