The client is a 29-year-old male who was referred by his girlfriend due to being “moody. ” Since the age of 14, the client has experienced repeated cycles of highs and lows and fits the description of Cyclothymic disorder. According to the Diagnostic and Statistical Manual of Mental Disorders, edition 5, (DSM-5), the criteria for cyclothymic disorder is periods involving milder hypomanic symptoms alternating with milder depression for at least 2 years (with no more than 2 months symptom-free) and having symptoms that have never met the criteria for a hypomanic, manic, or major depressive episode.
A hypomanic pisode is described as involving a period in which there is a definite, observable change in behavior occurring most of the day nearly every day during the episode for at least 4 days. The behavior change involves a consistently elevated, expansive, or irritable mood and unusual increases in energy or goal-directed activity.
It also must include at least three of the following symptoms: exaggerated self-esteem or feelings of grandiosity and extreme self-importance, decreased need for sleep; feeling rested after minimal sleep, usually talkative or seems pressured to keep talking, racing thoughts or frequent change of topics or deas, distractibility that may involve attention to unimportant environmental stimuli, increased social or work-related goal- directed activity, sexual activity, or physical restlessness, and impulsive involvement in activities that may have negative consequences (e. g. excessive spending, sexual promiscuity, gambling) (American Psychiatric Association, 2013).
The client meets the criteria for the hypomanic episodes of Cyclothymic disorder by showing inflated self-esteem and grandiosity with his overconfidence, having heightened social awareness, having excessive involvement in pleasurable activities through romiscuity, having a decreased need for sleep and frequently having irritable and hostile outbursts. The client’s periods of hypomania last 3-4 days (sometimes 7-10 days) which only occasionally meet the DSM-5 criteria for a hypomanic episodes (at least 4 days).
A Major Depressive Episode involves a change in functioning that includes specific symptoms most of the day nearly every day over a period of 2 weeks. The symptoms include: significant weight gain or loss or increases or decreases in appetite, persistent changes in sleep patterns, involving increased sleep or inability to sleep, observable restlessness or lowing of activity, persistent fatigue or loss of energy, excessive feelings of guilt or worthlessness, persistent difficulty with concentration or decision making, and suicidal behaviors or recurrent thoughts of death or suicide (American Psychiatric Association, 2013).
Through careful observation and self-reports of the client, the DSM-5’s criteria for Major Depression were not met. The client meets criteria for milder depression of Cyclothymic disorder through lacking energy and confidence as well as increased sleep by oversleeping 10-14 hours daily. During episodes of milder depression, the client is unable to omplete social and work obligations, which shows a lack of motivation and difficulty with concentration.
The client does not meet DSM-5 criteria for having major depressive episodes due to his periods of depression only lasting 4-7 days. Due to the lack of consistent episodes of hypomania and not meeting the criteria of having any major depressive episodes, the client has been diagnosed with Cyclothymic disorder instead of Bipolar II Disorder. The client has also admitted to the use of alcohol to enhance his periods of hypomania as well as help him sleep and marijuana to aid him in his daily routines.
The use of substances ay be altering with his symptoms thus making it difficult to diagnose accurately. Before the client starts treatment, he must try to stop abusing substances in order to make sure that specific pharmacological treatments are in correct doses and not having negative side effects. There are also no signs of comorbidity between cyclothymic disorder and another mental disorder. However, the use of alcohol and marijuana should be monitored closely to make sure there is no substance abuse or Substance-Use Disorder.
The treatments that should be used in helping intervene with this client are lithium to treat the ypomanic episodes and mood swings as well as the psychosocial therapy of Cognitive-Behavioral Therapy to treat the depressive episodes and overall disorder. Interventions to help the client regulate sleep patterns such as Relaxation Therapy should also be used. Antidepressants should not be used due to the lack of major depressive episodes, and therapy should be tried instead.
Giulio, Elie, Giulia, and Olavo found that, “misdiagnosis and consequent mistreatment are associated with a high risk of transforming cyclothymia into severe complex borderline-like bipolarity, especially with chronic and repetitive xposure to antidepressants and sedatives” (Giulio, Elie, Giulia, & Olavo, 2015). If client does not show any signs of improvement in depressive episodes or anxiety with therapy, antidepressants may be considered.
According to Kessing, Hellmund, Geddes, Goodwin, and Andersen, lithium is considered the most effective mood-stabilizing medication for those who respond to its effects (Kessing et al. , 2011). Lithium will be prescribed on an ongoing basis in order to make sure blood levels are not too concentrated with the drug. The client will also be monitored to ensure that medications are taken regularly. Since the client has reported to use of alcohol and marijuana, there is a high chance that the client will revert back into self-medication. This may alter the effects of the mood- stabilizer and should be watched.
Fava, Rafanelli, Tomba, Guidi, and Grandi completed a study of 62 patients diagnosed with cyclothymic disorder in which patients were randomly assigned to Cognitive-Behavioral Therapy (CBT) or clinical management. CBT, which addresses both polarities of mood swings and comorbid anxiety, was found to yield significant and persistent benefits in cyclothymic disorder (Fava et al. , 2011). CBT comprises a variety of procedures, such as cognitive restructuring, stress inoculation training, problem solving, skills training, relaxation training and others.
These procedures are used to help clients recognize and develop strengths and coping skills which they can then generalize and apply to different aspects of their life” (Wyatt and Seid, 2009). Cognitive-Behavioral Therapy will help the client to manage his illness through the teaching of emotional regulation and avoiding stress from overly ambitious goal setting. Finally, sleep is linked with emotional regulation and brain activity (Gujar, Yoo, Hu, & Walker, 2011). The client has been using other substances to help aid him in his sleep patterns.
When the client is experiencing a hypomanic episode, he experiences sleep deprivation and when he is experiencing his depressive episodes, he finds himself oversleeping. The use of relaxation therapy can be a helpful tool so that the client will be able to quiet his mind and body in preparation for sleep. Cognitive- Behavioral therapy is also an aid in sleep regulation and can be used to help the client. As of right now, the client does not recognize his mental disorder and only admits that he has good” and “bad” times.
However, it is affecting his social life and he has alienated many friendships. His mood changes are noticeable to others such as his girlfriend and affect his job as a car salesman. After being diagnosed with Cyclothymic disorder, the client now will be started on a personalized amount of the mood-stabilizer, lithium, and will start Cognitive-Behavioral Therapy as well as relaxation therapy in order to change cognitive distortions that lead to certain behaviors as well as start a more stable sleep pattern to help with his emotional regulation and depressive and hypomanic episodes.
