You’ve heard of dysthymia, but it’s not just a mild type of depression. You’ve heard of cyclothymia, but how frequently do you diagnose it? You’ve probably never heard of hyperthymia. These are the mood temperaments, a class definition which in itself is an important point, unlike the DSM vague term of “disorders”, which doesn’t identify what kind of condition is present. In DSM-III and IV, dysthymia and cyclothymia were placed on “axis I”, not on axis II with the personality conditions, and thus most people do not make the connection that these are temperaments, i.e., part of personality. They are not separate “disorders” unrelated to personality. This always was the concept of dysthymia and cyclothymia dating back at least a century.
In this article, we’ll review what these conditions mean, historically and scientifically.
Let’s look in some more detail into the clinical psychopathology of mood temperaments, for they are more complex than presented in DSM. A useful resource is the TEMPS (Temperament Evaluation scale from Memphis, Pisa, and San Diego) scale, which is the most validated research scale to assess mood temperaments. As an aid to clinical diagnosis, a short self-report TEMPS scale (37 or 50 item) can be invaluable.
At one level, the temperaments can be defined as mild versions of mood states, but they go beyond that initial concept to include basic differences in personality traits and in energy levels, as expressed in sleep patterns and behaviors, such as sexual and social or work-related activities. Hence, the following brief descriptions apply:
Hyperthymia involves a mild manic state as part of one’s basic temperament. Such persons are high in energy, need less sleep than most people (often 4-6 hours nightly), have high sex drives, are highly social, extroverted, often workaholics, and often humorous. They are described as the life of the party, as fun-loving, and can engage in risk-taking behaviors that others avoid, such as skydiving or bungee-jumping or motorcycle or airplane flying. They dislike routine, and are spontaneous. They can be quite anxious and inattentive.
Dysthymia is the reverse, a mild depressive state as part of one’s basic temperament. Such persons are low in energy, need more sleep than most people (often 9-11 hours nightly), have low sex drives, are socially anxious, introverted, low in work productivity, and not humorous. They avoid risk-taking behaviors, are devoted to routine, and can be obsessive. They can be quite anxious but not usually inattentive.
Cyclothymia involves constant alternation between mild manic and depressive states on a day-to-day, or a few days at time, basis. Such persons go up and down in mood and energy and activity levels, though they can be generally mostly extroverted and productive and social. They tend to be risk-takers at times, and are unpredictable, and spontaneous. They can be quite anxious and inattentive.
The concept of mood temperaments was best systematized about a century ago by the German psychiatrist Ernst Kretschmer. These ideas predate Kretschmer, with descriptions in Kraepelin’s work and earlier writers. In Kraepelin’s texts, we read about “manic temperaments” and “depressive temperaments”. Kretschmer developed these concepts, which gradually led to the terms of hyperthymia and dysthymia respectively. Dysthymia is an old term, found in ancient Greek Hippocratic texts, referring to depressive moods. “Thymia” mean emotion, and “dys” mean low or sad. In 19th century literature in France and Germany, the word “cyclothymia” was used to reflect temperaments that were up and down. Kraepelin’s concept of manic-depressive insanity wasn't developed by him until 1898. At the same time, he incorporated the old concepts of dysthymia and cyclothymia as depressive and manic temperaments. A few decades later, Kretschmer extended the idea to a "hypomanic" personality (hyperthymia) to capture the three main mood temperaments.
In the original view of Kraepelin and Kretschmer, these temperaments are mild variations of manic-depressive illness. They are not separate or independent diseases or disorders, as the DSM system sets them up. They are part of the same condition, just mild versions, “formes frustes”, as in the French term.
This is no different than saying that mild adrenal insufficiency is related to but not the same as Addison’s disease; or that mild hypothyroidism is related to but not the same as Grave’s disease. Mood temperaments are different in severity but not in kind from severe depressive or manic illness.
This concept was lost in the mid to late 20th century, as psychoanalytic concepts rose in prominence, and Kretschmer’s views were lost. The concept of personality was seen through a psychological, rather than biological, lens, and related to psychoanalytic concepts of emotional development. As DSM-III evolved in the 1970s, these psychoanalytic approaches were codified into the definitions of the “personality disorders,” which mainly use psychoanalytic constructs. The terms “dysthymia” and cyclothymia also were resuscitated, but not as mild versions of unipolar depression or bipolar illness, but rather as separate labels. Dysthymia in particular was added to allow for a different term to replace “neurotic depression,” which was thought of in psychoanalytic terms. This use of the concept of dysthymia had nothing to do with the traditional concept of this condition as a mood temperament.
Cyclothymia was included for descriptive reasons, it seems, and the term “hyperthymia” was never included in DSM-III or its follow-up revisions, for unclear reasons.
Hence after DSM-III, if these terms were used, they were never understood in their original context. Dysthymia was used frequently as a comorbidity, added to generalized anxiety disorder, to capture that same concept of “neurotic depression” which DSM-III sought to rename. Cyclothymia was used infrequently. Hyperthymia was forgotten completely.
Instead personality was conceived solely in psychoanalytic ways, with special popularity of borderline and narcissistic constructs.
At the same time, a huge literature on dimensional personality traits was completely ignored by DSM-III and its follow-up revisions. Yet, the experimental psychology research world continued to conduct that research and validated a number of classic personality traits, such as neuroticism, extroversion, and openness to experience (NEO).
At the same time, beginning in the 1980s, some researchers began to return to the original concept of mood temperaments, and began to study dysthymia, cyclothymia, and hyperthymia - not in their DSM descriptions - but as mild versions of depressive or bipolar illness.
They found that indeed the ideas of Kraepelin and Kretschmer could be confirmed with newer research. Often, patients with bipolar illness, for instance, had baseline dysthymia in between their depressive and manic episodes. Or patients with unipolar depression had baseline hyperthymia in between their depressive episodes.
Further, they found that the relatives of those patients often had just mood temperaments; in other words, while some relatives had full-blown unipolar depression or bipolar illness, others only had dysthymia all the time, or cyclothymia all the time, without any intervening full depressive or manic episodes.
These observations confirmed the perspective of Kretschmer and Kraepelin that these mood temperaments are biologically and genetically related mild variants of manic-depressive illness.
The rediscovery of mood temperaments in recent years has allowed for a new perspective on personality. Instead of only using DSM-based psychoanalytic concepts of personality disorders, we can take a more dimensional perspective, using mood temperaments. Mood temperaments are dimensional because they simply are milder versions of mood illnesses, as opposed to being categorically different conditions. Thus, a patient can have both unipolar depression and cyclothymic temperament, or both bipolar illness and hyperthymic temperament. The conditions are not mutually exclusive.
Further, much of the mood lability and impulsivity that is diagnosed using the DSM system only through the lens of personality disorders can be reconceived through the lens of mood temperaments as mild versions of manic-depressive illness.
For instance, patients with cyclothymia have constant mood lability and impulsive sexuality, just as is defined as part of borderline personality. Those traits do not distinguish the two conditions; other traits would need to be considered instead (such as sexual trauma and self-cutting in borderline personality, versus bipolar genetics in cyclothymia).
Further mood temperaments provide some clinical implications, if used, that go beyond many common assumptions in clinical practice.
For example, if a patient presents with a first depressive episode at age 50, without any prior depressive or manic episodes, it often is assumed that this presentation is unusual, since mood episodes should begin by age 30 or earlier in unipolar or bipolar illness. If that patient had hyperthymic temperament at baseline, though, then the age of onset is not unusual. Mood temperaments are present throughout life; in other words, they are present in childhood and adolescence and then persist. Thus the age of onset of abnormal mood in that patient is not 50, with the first depression, but 15, with onset of definable hyperthymia.
Indeed this presentation is typical: Many persons have hyperthymia or cyclothymia for decades, before their first depressive, or even manic, episode in middle-age or later life. This late-life onset depression and mania has been reported in the past. But few researchers have assessed a link with baseline abnormal mood temperaments.
Often persons with hyperthymia or cyclothymia will have problems with attention, due to constant or frequent manic states. Since these mood temperaments are not diagnosed commonly in current clinical practice, clinicians instead notice the attentional symptoms mainly. With current pharmaceutical marketing and DSM-based support, many such persons get diagnosed with “adult ADD.” Since amphetamines improve attention symptomatically in all persons, including normal controls, clinicians and patients often make the mistaken judgment that such adult ADD exists and is improved by those amphetamine stimulants. In fact, underlying manic symptoms can worsen with amphetamines, and partial improvement of attentional symptoms often comes at the expense of worsening of other aspects of hyperthymia, such as sexual impulsivity. Sometimes full manic episodes can be caused. Other times, full depressive episodes can be caused, as the manic state switches into its opposite pole.
Instead, treatment of manic temperaments with low-dose mood stabilizers can produce similar attentional benefits as seen with amphetamines, without worsening, or risk of worsening, of mood symptoms as described above.
The treatment of mood temperaments, if undertaken, should involve low dose mood stabilizer medications, based on the PL experience. For cyclothymia or hyperthymia, this would involve low-dose lithium (300-600 mg/d) or valproate (250-500 mg/d) or possibly standard dose lamotrigine (50-100 mg/d). For dysthymia, it would involve low dose standard monoamine agonists (antidepressants). When full clinical depressive episodes are present, along with mood temperaments, then the above medication classes may be needed in full doses, either by themselves, or with standard monoamine agonists.
The research literature is limited because mood temperaments have either not been included in DSM systems, or not identified as temperaments. Hence researchers and pharmaceutical companies have not conducted much research on their treatment. Further research is needed to clarify and revise the above recommendations. For now, PL recommends clinicians start with these ideas and be flexible in their practice, revising their treatment patterns based on their own clinical observations.