Journal of Abnormal Child Psychology

, Volume 41, Issue 3, pp 367–378 | Cite as

Examining the Validity of Cyclothymic Disorder in a Youth Sample: Replication and Extension

  • Anna Van Meter
  • Eric A. Youngstrom
  • Christine Demeter
  • Robert L. Findling


DSM-IV-TR defines four subtypes of bipolar disorder (BP): bipolar I, bipolar II, cyclothymic disorder and bipolar not otherwise specified (NOS). However, cyclothymic disorder in children is rarely researched, or often subsumed in an “NOS” category. The present study tests the replicability of findings from an earlier study, and expands on the criterion validity of cyclothymic disorder in youth. Using the Robins and Guze (1970) framework we examined the validity of cyclothymic disorder as a subtype of BP. Using a youth (ages 5–17) outpatient clinical sample (N = 894), participants with cyclothymic disorder (n = 53) were compared to participants with other BP spectrum disorders (n = 399) and to participants with non-bipolar disorders (n = 442). Analyses tested differences in youth with cyclothymic disorder and bipolar disorder not otherwise specified who do, and those who do not, have a parent with BP. Compared to youth with non-bipolar disorders, youth with cyclothymic disorder had higher irritability (p < 0.001), more comorbidity (p < 0.001), greater sleep disturbance (p < 0.005), and were more likely to have a family history of BP (p < 0.001). Cyclothymic disorder was associated with a younger age of onset compared to depression (p < 0.001) and bipolar II (p = 0.05). Parental BP status was not significantly associated with any variables. Results support that cyclothymic disorder belongs on the bipolar spectrum. Epidemiological studies indicate that cyclothymic disorder is not uncommon and involves significant impairment. Failing to differentiate between cyclothymic disorder and bipolar NOS limits our knowledge about a significant proportion of cases of bipolarity.


Cyclothymic disorder Pediatric bipolar disorder Validation Replication Subthreshold 


  1. Akiskal, H. (1996). The temperamental foundations of affective disorders. In C. Mundt & H. L. Freeman (Eds.), Interpersonal factors in the origin and course of affective disorders (pp. 3–30). London: RCPsych Publications.Google Scholar
  2. Akiskal, H., & Akiskal, K. (1992). Cyclothymic, hyperthymic, and depressive temperaments as subaffective variants of mood disorders. American Psychiatric Press Review of Psychiatry, 11, 43–62.Google Scholar
  3. Akiskal, H., Djenderedjian, A., Rosenthal, R., & Khani, M. (1977). Cyclothymic disorder: validating criteria for inclusion in the bipolar affective group. The American Journal of Psychiatry, 134, 1227–1233.PubMedGoogle Scholar
  4. Akiskal, H., Lancrenon, S., & Hantouche, E. (2006). Validating the soft bipolar spectrum in the French National EPIDEP Study: the prominence of BP-II 1/2. Journal of Affective Disorders, 96, 207–213. doi:10.1016/j.jad.2006.03.011.PubMedCrossRefGoogle Scholar
  5. Andreasen, N. C., Endicott, J., Spitzer, R. L., & Winokur, G. (1977). The family history method using diagnostic criteria: reliability and validity. Archives of General Psychiatry, 34, 1229–1235. doi:10.1001/archpsyc.1977.01770220111013.PubMedCrossRefGoogle Scholar
  6. Angst, J., Merikangas, K., & Preisig, M. (1997). Subthreshold syndromes of depression and anxiety in the community. The Journal of Clinical Psychiatry, 58(Suppl 8), 6–10.PubMedGoogle Scholar
  7. Axelson, D., Birmaher, B., Strober, M., Gill, M. K., Valeri, S., Chiappetta, L., et al. (2006). Phenomenology of children and adolescents with bipolar spectrum disorders. Archives of General Psychiatry, 63, 1139–1148. doi:10.1001/archpsyc.63.10.1139.PubMedCrossRefGoogle Scholar
  8. Baker, N., Berry, S., & Adler, L. (1987). Family diagnoses missed on a clinical inpatient service. The American Journal of Psychiatry, 144, 630.PubMedGoogle Scholar
  9. Berk, M., Dodd, S., Callaly, P., Berk, L., Fitzgerald, P., de Castella, A., et al. (2007). History of illness prior to a diagnosis of bipolar disorder or schizoaffective disorder. Journal of Affective Disorders, 103, 181–186. doi:10.1016/j.jad.2007.01.027.PubMedCrossRefGoogle Scholar
  10. Biederman, J., Mick, E., Faraone, S., Spencer, T., Wilens, T., & Wozniak, J. (2000). Pediatric mania: a developmental subtype of bipolar disorder? Biological Psychiatry, 48(6), 458–466. doi:10.1016/S0006-3223(00)00911-2.PubMedCrossRefGoogle Scholar
  11. Birmaher, B., Axelson, D., Strober, M., Gill, M. K., Valeri, S., Chiappetta, L., et al. (2006). Clinical course of children and adolescents with bipolar spectrum disorders. Archives of General Psychiatry, 63, 175–183. doi:10.1001/archpsyc.63.2.175.PubMedCrossRefGoogle Scholar
  12. Birmaher, B., Axelson, D., Goldstein, B., Strober, M., Gill, M. K., Hunt, J., et al. (2009). Four-year longitudinal course of children and adolescents with bipolar spectrum disorders: The course and outcome of bipolar youth (COBY) study. The American Journal of Psychiatry, 166, 1–10. doi:10.1176/appi.ajp.2009.08101569.CrossRefGoogle Scholar
  13. Brook, J., Cohen, P., & Brook, D. (1998). Longitudinal Study of Co-occurring Psychiatric Disorders and Substance Use. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 322–330. doi:10.1097/00004583-199803000-00018.PubMedCrossRefGoogle Scholar
  14. Chang, K. (2008). Treatment of children and adolescents at high risk for bipolar disorder. In B. Geller & M. DelBello (Eds.), Treatment of Bipolar Disorder in Children and Adolescents. New York: The Guilford Press.Google Scholar
  15. Chang, K., & Steiner, H. (2003). Offspring studies in child and early adolescent bipolar disorder. In B. Geller & M. DelBello (Eds.), Bipolar disorder in childhood and early adolescence (pp. 107–129). New York: Guilford.Google Scholar
  16. Cicero, D., Epler, A., & Sher, K. (2009). Are there developmentally limited forms of bipolar disorder? Journal of Abnormal Psychology, 118, 431–447. doi:10.1037/a0015919.PubMedCrossRefGoogle Scholar
  17. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale: Lawrence Erlbaum Associates, Inc.Google Scholar
  18. Cohen, P., Cohen, J., Aiken, L., & West, S. (1999). The problem of units and the circumstance for POMP. Multivariate Behavioral Research, 34, 315. doi:10.1207/S15327906MBR3403_2.CrossRefGoogle Scholar
  19. Cyranowski, J., Frank, E., Young, E., & Shear, M. K. (2000). Adolescent onset of the gender difference in lifetime rates of major depression: a theoretical model. Archives of General Psychiatry, 57, 21–27. doi:10.1001/archpsyc.57.1.21.PubMedCrossRefGoogle Scholar
  20. DelBello, M., & Geller, B. (2001). Review of studies of child and adolescent offspring of bipolar parents. Bipolar Disorders, 3, 325–334. doi:10.1034/j.1399-5618.2001.30607.x.PubMedCrossRefGoogle Scholar
  21. Depue, R., Slater, J., Wolfstetter-Kausch, H., Klein, D., Goplerud, E., & Farr, D. (1981). A behavioral paradigm for identifying persons at risk for bipolar depressive disorder: a conceptual framework and five validation studies. Journal of Abnormal Psychology, 90, 381–437. doi:10.1037/0021-843X.90.5.381.PubMedCrossRefGoogle Scholar
  22. Duffy, A., Alda, M., Crawford, L., Milin, R., & Grof, P. (2007). The early manifestations of bipolar disorder: a longitudinal prospective study of the offspring of bipolar parents. Bipolar Disorders, 9, 828–838. doi:10.1111/j.1399-5618.2007.00421.x.PubMedCrossRefGoogle Scholar
  23. Endicott, J., & Spitzer, R. (1978). A diagnostic interview: the schedule for affective disorders and schizophrenia. Archives of General Psychiatry, 35, 837–844.PubMedCrossRefGoogle Scholar
  24. Evans, L., Akiskal, H., Keck, P., McElroy, S., Sadovnick, A. D., Remick, R., et al. (2005). Familiality of temperament in bipolar disorder: support for a genetic spectrum. Journal of Affective Disorders, 85, 153–168.PubMedCrossRefGoogle Scholar
  25. Faul, F., Erdfelder, E., Buchner, A., & Lang, A. G. (2009). Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behavior Research Methods, 41, 1149–1160. doi:10.3758/brm.41.4.1149.PubMedCrossRefGoogle Scholar
  26. Findling, R. L., Gracious, B. L., McNamara, N. K., Youngstrom, E. A., Demeter, C. A., Branicky, L. A., et al. (2001). Rapid, continuous cycling and psychiatric co-morbidity in pediatric bipolar I disorder. Bipolar Disorders, 3, 202–210. doi:10.1034/j.1399-5618.2001.30405.x.PubMedCrossRefGoogle Scholar
  27. Findling, R., Youngstrom, E., McNamara, N., Stansbrey, R., Demeter, C., Bedoya, D., et al. (2005). Early symptoms of mania and the role of parental risk. Bipolar Disorders, 7, 623–634. doi:10.1111/j.1399-5618.2005.00260.x.PubMedCrossRefGoogle Scholar
  28. Geller, B., Tillman, R., Bolhofner, K., & Zimerman, B. (2008). Child bipolar I disorder: prospective continuity with adult bipolar I disorder; characteristics of second and third episodes; predictors of 8-year outcome. Archives of General Psychiatry, 65, 1125–1133. doi:10.1001/archpsyc.65.10.1125.PubMedCrossRefGoogle Scholar
  29. Goldstein, T., Birmaher, B., Axelson, D., Ryan, N., Strober, M., Gill, M. K., et al. (2005). History of suicide attempts in pediatric bipolar disorder: factors associated with increased risk. Bipolar Disorders, 7, 525–535. doi:10.1111/j.1399-5618.2005.00263.x.PubMedCrossRefGoogle Scholar
  30. Hantouche, E. (2009).Validating cyclothymia as a distinct variant of bipolarity. Paper presented at the International Review of Bipolar Disorders, Lisbon.Google Scholar
  31. Harvey, A. G. (2009). The adverse consequences of sleep disturbance in pediatric bipolar disorder: implications for intervention. Child and Adolescent Psychiatric Clinics of North America, 18, 321–338. doi:10.1016/j.chc.2008.11.006.PubMedCrossRefGoogle Scholar
  32. Harvey, A., Mullin, B., & Hinshaw, S. (2006). Sleep and circadian rhythms in children and adolescents with bipolar disorder. Development and Psychopathology, 18, 1147–1168. doi:10.1017/S095457940606055X.PubMedCrossRefGoogle Scholar
  33. Howland, R., & Thase, M. (1993). A Comprehensive Review of Cyclothymic Disorder. The Journal of Nervous and Mental Disease, 181, 485–493.PubMedCrossRefGoogle Scholar
  34. Judd, L., & Akiskal, H. (2003). The prevalence and disability of bipolar spectrum disorders in the US population: Re-analysis of the ECA database taking into account subthreshold cases. Journal of Affective Disorders, 73, 123–131. doi:10.1016/S0165-0327(02)00332-4.PubMedCrossRefGoogle Scholar
  35. Judd, L., Akiskal, H., Schettler, P., Endicott, J., Maser, J., Solomon, D., et al. (2002). The long-term natural history of the weekly symptomatic status of bipolar I disorder. Archives of General Psychiatry, 59, 530–537. doi:10.1001/archpsyc.59.6.530.PubMedCrossRefGoogle Scholar
  36. Kandel, D., Johnson, J., Bird, H., Canino, G., Goodman, S., Lahey, B., et al. (1997). Psychiatric Disorders Associated with Substance Use Among Children and Adolescents: findings from the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. Journal of Abnormal Child Psychology, 25, 121–132. doi:10.1023/A:1025779412167.PubMedCrossRefGoogle Scholar
  37. Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., et al. (1997). Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 980–988. doi:10.1097/00004583-199707000-00021.PubMedCrossRefGoogle Scholar
  38. Kessler, R., Avenevoli, S., & Merikangas, K. (2001). Mood disorders in children and adolescents: an epidemiologic perspective. Biological Psychiatry, 49, 1002–1014. doi:10.1016/S0006-3223(01)01129-5.PubMedCrossRefGoogle Scholar
  39. Klein, D., Depue, R., & Slater, J. (1986). Inventory identification of cyclothymia: IX. Validation in offspring of bipolar I patients. Archives of General Psychiatry, 43, 441–445.PubMedCrossRefGoogle Scholar
  40. Kowatch, R., Fristad, M., Birmaher, B., Wagner, K., Findling, R., & Hellander, M. (2005). Treatment guidelines for children and adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 213–235. doi:10.1097/00004583-200503000-00006.PubMedCrossRefGoogle Scholar
  41. Kowatch, R., Youngstrom, E., Danielyan, A., & Findling, R. (2005). Review and meta-analysis of the phenomenology and clinical characteristics of mania in children and adolescents. Bipolar Disorders, 7, 483–496. doi:10.1111/j.1399-5618.2005.00261.x.PubMedCrossRefGoogle Scholar
  42. Lewinsohn, P., Klein, D., & Seeley, J. (1995). Bipolar disorders in a community sample of older adolescents: prevalence, phenomenology, comorbidity, and course. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 454–463.PubMedCrossRefGoogle Scholar
  43. Lewinsohn, P., Klein, D., & Seeley, J. (2000). Bipolar disorder during adolescence and young adulthood in a community sample. Bipolar Disorders, 2, 281–293. doi:10.1034/j.1399-5618.2000.20309.x.PubMedCrossRefGoogle Scholar
  44. Marchand, W., Wirth, L., & Simon, C. (2006). Delayed Diagnosis of Pediatric Bipolar Disorder in a Community Mental Health Setting. Journal of Psychiatric Practice, 12, 128–133.PubMedCrossRefGoogle Scholar
  45. McElroy, S., Strakowski, S., West, S., Keck, P., Jr., & McConville, B. (1997). Phenomenology of adolescent and adult mania in hospitalized patients with bipolar disorder. The American Journal of Psychiatry, 154, 44–49.PubMedGoogle Scholar
  46. Merikangas, K., Akiskal, H., Angst, J., Greenberg, P., Hirschfeld, R., Petukhova, M., et al. (2007). Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey Replication. Archives of General Psychiatry, 64, 543–552. doi:10.1001/archpsyc.64.5.543.PubMedCrossRefGoogle Scholar
  47. Meyers, O., & Youngstrom, E. (2008). A Parent General Behavior Inventory subscale to measure sleep disturbance in pediatric bipolar disorder. The Journal of Clinical Psychiatry, 69, 840–843. doi:10.4088/JCP.v69n0518.PubMedCrossRefGoogle Scholar
  48. Miklowitz, D., & Chang, K. (2008). Prevention of bipolar disorder in at-risk children: theoretical assumptions and empirical foundations. Development and Psychopathology, 20, 881–897. doi:10.1017/S0954579408000424.PubMedCrossRefGoogle Scholar
  49. Moreno, C., Laje, G., Blanco, C., Jiang, H., Schmidt, A. B., & Olfson, M. (2007). National Trends in the Outpatient Diagnosis and Treatment of Bipolar Disorder in Youth. Archives of General Psychiatry, 64, 1032–1039. doi:10.1001/archpsyc.64.9.1032.PubMedCrossRefGoogle Scholar
  50. Orvaschel, H. (1994). Schedule for affective Disorders and schizophrenia for School-Age Children-Epidemiologic Version (Vol. Fifth revision). Fort Lauderdale: Nova Southeastern University.Google Scholar
  51. Perlis, R., Miyahara, S., Marangell, L., Wisniewski, S., Ostacher, M., DelBello, M., et al. (2004). Long-term implications of early onset in bipolar disorder: data from the first 1000 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD). Biological Psychiatry, 55, 875–881. doi:10.1016/j.biopsych.2004.01.022.PubMedCrossRefGoogle Scholar
  52. Robins, E., & Guze, S. (1970). Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. The American Journal of Psychiatry, 126, 983–987. doi:10.1176/appi.ajp.126.7.983.PubMedGoogle Scholar
  53. Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P., Bird, H., et al. (1983). A Children's Global Assessment Scale (CGAS). Archives of General Psychiatry, 40, 1228–1231. doi:10.1001/archpsyc.1983.01790100074010.PubMedCrossRefGoogle Scholar
  54. Shankman, S., Lewinsohn, P., Klein, D., Small, J., Seeley, J., & Altman, S. (2009). Subthreshold conditions as precursors for full syndrome disorders: a 15-year longitudinal study of multiple diagnostic classes. Journal of Child Psychology and Psychiatry, 50, 1485–1494. doi:10.1111/j.1469-7610.2009.02117.x.PubMedCrossRefGoogle Scholar
  55. Spencer, T., Biederman, J., Wozniak, J., Faraone, S., Wilens, T., & Mick, E. (2001). Parsing pediatric bipolar disorder from its associated comorbidity with the disruptive behavior disorders. Biological Psychiatry, 49, 1062–1070. doi:10.1016/S0006-3223(01)01155-6.PubMedCrossRefGoogle Scholar
  56. Van Meter, A., Moreira, A., & Youngstrom, E. (2011a). Meta-analysis of epidemiologic studies of pediatric bipolar disorder. The Journal of Clinical Psychiatry, 72, 1250–1256. doi:10.4088/JCP.10m06290.CrossRefGoogle Scholar
  57. Van Meter, A., Youngstrom, E., Youngstrom, J., Feeny, N., & Findling, R. (2011b). Examining the validity of cyclothymic disorder in a youth sample. Journal of Affective Disorders, 132, 55–63. doi:10.1016/j.jad.2011.02.004.CrossRefGoogle Scholar
  58. Wilens, T., Biederman, J., Millstein, R., Wozniak, J., Hahesy, A., & Spencer, T. (1999). Risk for Substance Use Disorders in Youths With Child- and Adolescent-Onset Bipolar Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 680–685. doi:10.1097/00004583-199906000-00014.PubMedCrossRefGoogle Scholar
  59. Wozniak, J., Biederman, J., Kiely, K., Ablon, J. S., Faraone, S., Mundy, E., et al. (1995). Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 867–876. doi:10.1097/00004583-199507000-00010.PubMedCrossRefGoogle Scholar
  60. Youngstrom, E. (2009). Definitional issues in bipolar disorder across the life cycle. Clinical Psychology: Science and Practice, 16, 140–160. doi:10.1111/j.1468-2850.2009.01154.x.CrossRefGoogle Scholar
  61. Youngstrom, E., Findling, R., Danielson, C., & Calabrese, J. (2001). Discriminative validity of parent report of hypomanic and depressive symptoms on the General Behavior Inventory. Psychological Assessment, 13, 267–276. doi:10.1037/1040-3590.13.2.267.PubMedCrossRefGoogle Scholar
  62. Youngstrom, E., Youngstrom, J., & Starr, M. (2005). Bipolar diagnoses in community mental health: Achenbach Child Behavior Checklist profiles and patterns of comorbidity. Biological Psychiatry, 58, 569–575. doi:10.1016/j.biopsych.2005.04.004.PubMedCrossRefGoogle Scholar
  63. Youngstrom, E., Birmaher, B., & Findling, R. (2008). Pediatric bipolar disorder: validity, phenomenology, and recommendations for diagnosis. Bipolar Disorders, 10, 194–214. doi:10.1111/j.1399-5618.2007.00563.x.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Anna Van Meter
    • 1
  • Eric A. Youngstrom
    • 1
  • Christine Demeter
    • 2
  • Robert L. Findling
    • 2
  1. 1.CB 3270 University of North CarolinaChapel HillUSA
  2. 2.Case Western Reserve UniversityClevelandUSA

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