# 18 - Other affective disorders

# Other affective disorders

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o Rapid cycling: When at least four episodes of bipolar 
disorder occur within a period of one year, the condition is 
described  as  ‘rapid  cycling’.  Some  patients  with BPAD 
have more than 4 episodes per year; they are called rapid 
cyclers. 70-80% of rapid cyclers are women. Some of the 
factors associated with the rapid cycling include the use of 
tricyclic anti-depressant, low thyroxine level, being a 
female patient, Bipolar type 2 pattern of illness and the 
presence of neurological disease. Ultra-rapid cycling refers 
to the situation when fluctuations are over days or even 
hours. 
o Postpartum onset refers to the onset of mania, hypomania 
or depression with 4 weeks of childbirth. 
o Seasonal pattern refers to recurrences over several years 
with most episodes typically start (and end) at the same 
time each year. 
 
Secondary Mania: This can occur as a result of misuse of alcohol or illicit drugs and can also occur with 
some prescribed drugs such as Levodopa and corticosteroids. The drug induced state wanes with the 
clearance of the drug responsible. It can also occur in certain organic conditions such as thyroid disease, 
multiple sclerosis and lesions involving cortical and or subcortical areas of the brain. 
Bipolar 3 is a variant used to describe minimal depression complicated by antidepressant-induced 
hypomania – these patients fall into bipolar spectrum (in ICD: this is coded as unspecified type). 
Other affective disorders 
Persistent affective disorders: This includes dysthymia and cyclothymia respectively for unipolar and 
bipolar patterns of symptoms that fail to meet criteria for severity but which are of long duration and 
sufficient to cause impairment. 
 Dysthymia (ICD-10)/dysthymic disorder (DSM-IV): Chronic, mildly depressed mood and 
diminished enjoyment, not severe enough to be considered a depressive illness. Clinical features 
include depressed mood (< 2yrs), Reduced/increased appetite, Insomnia/hypersomnia, reduced 
energy/fatigue, Low self-esteem, Poor concentration and thoughts of hopelessness. Double 
Depression describes episodes of major depression superimposed on Dysthymia; the prognosis 
and treatment response may be worse. 
 Cyclothymia:  There  is  also  a  subclinical  presentation  ”cyclothymia”  in  which  an individual may 
experience oscillating high and low moods, without ever having a significant manic or depressive 
episode (numerous periods of mild depression and mild elation) and not sufficiently severe or 
DSM-5 AND BIPOLAR DISORDER 
Criterion A for manic and hypomanic 
episodes now includes an emphasis on 
changes in activity and energy as well as 
mood 
Separate description of mixed episode 
has  been  removed.  A  new  specifier  “with  
mixed  features”  has  been  added:  to  
qualify for this specifier, there is no need 
to simultaneously fulfill criteria for both 
mania and major depressive episode. 
Presence of some features of the opposite 
pole of mood disturbance is sufficient.

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prolonged to fulfill the criteria for bipolar affective disorder or recurrent depressive disorder. An 
individual usually perceives these mood swings as being unrelated to life events. 
 
Seasonal Affective Disorder (SAD) is included in ICD-10 in the Annex. 
 Many patients exhibit a seasonal pattern for their affective illness. The classical presentation is 
depression with reversed biological features in winter. These do not constitute SAD. To diagnose 
SAD, ICD-10 specifies that 3 or more affective episodes must occur, with onset within the same 90 
day period of the year, for 3 or more consecutive years. Remissions should occur within a defined 
90-day period of the year. Seasonal episodes substantially outnumber any non-seasonal episodes 
that may occur. 
 The affective episode is most commonly depressive in nature. Atypical features like hypersomnia, 
increased appetite, carbohydrate craving and weight gain are common. Most commonly, the onset 
is in autumn/winter (when daylight is less), and 
resolution is in spring/summer (when daylight is 
more). 
 Phototherapy is a treatment that is popular in 
SAD. Bright light (10,000 lux) is considered to be 
superior to dim light. Daily exposure is usually 
for 1 
to 2 hours. The benefit may become apparent 
within a few days. Maintenance treatment is 
given for the next few months until the usual time of remission. 
 
 
 
 
 
 
 
 
 
 
DSM-5 AND DYSTHYMIA 
Dysthymia of DSM-IV is now 
reclassified as persistent depressive 
disorder, a diagnosis that includes both 
chronic major depressive disorder and 
the previous dysthymic disorder.