Gin S. Malhi: A critical analysis of concepts in psychiatry.

Gin S.Malhi and Erica Bell:Fake views: Cyclothymia. Ditering disorder 


Nassir Ghaemi’s comments


        In their essay on cyclothymia, Gin Malhi and Erica Bell note  that clinicians rarely use the concept of cyclothymic “disorder” and they review DSM and ICD definitions. Despite an initial nod to Kahlbaum, though, they make the standard error of discussing a diagnostic question solely through the DSM/ICD lens, even if to criticize it. 

        The key is to understand what cyclothymia meant historically and scientifically, before DSM and ICD came along to ruin everything.  A 100 years ago, beginning with Kahlbaum and also with Kraepelin and Kretschmer, cyclothymia meant the biologically and genetically related mild personality variant of manic-depressive illness (MDI). It occurred in patients with MDI in between their full mood episodes, as their baseline temperament and it occurred in relatives of those patients as their baseline personality, often with few or no mood episodes of any kind.

        This concept of mood temperaments, so central to the whole notion of Kraepelin’s MDI, has been lost in DSM and ICD. Hyperthymia is dropped completely. Dysthymia and cyclothymia were kept in name but redefined as separate “axis I” “disorders,” on a par with unipolar depression or bipolar illness, whereas they are completely different. They are personality states, not diseases.

        A contribution to the critique of cyclothymia would be to bring out this scientifically sound concept of mood temperaments, as opposed to DSM “disorders,” to criticize the latter and explain the former.

        In my clinical experience, it took me two decades to realize how revolutionary and helpful the concept of mood temperaments can be in clinical practice. Like most clinicians, I rarely used cyclothymia for two decades and my clinical work suffered. Now I see that many patients with “generalized anxiety disorder” or “major depressive disorder” or even presumed bipolar illness in fact have cyclothymia all or most of the time.  I’ve seen how patients who failed a dozen serotonin reuptake inhibitors of GAD or MDD respond to low dose divalproex or lithium for cyclothymia.  I’ve seen many patients get better with fewer medications at lower doses than I used to give once I got out of the straitjacket of focusing on severe “disorders” and being more willing to look for the milder mood temperaments.

        In this process the TEMPS-A self-report scale has been an invaluable and practical clinical aid. I say all this as someone who was rather skeptical about mood temperaments for years. I heard Hagop Akiskal lecture on it and read his papers (Akiskal 2005; Rihmer, Akiskal, Rihmer and Akiskal 2010). Athanasios Koukopoulos brought it to my attention repeatedly (Ghaemi and Vohringer 2017). It took years for me to begin to take the concept seriously (Vohringer, Whitham, Thommi et al. 2012), and once I did, I have felt that my clinical skills have improved multiple-fold in terms of really being able to help more people with the whole spectrum of MDI.

        We should teach clinicians what they don’t understand, rather than codify their lack of understanding in a new misunderstanding of such a key concept to daily psychiatric practice as cyclothymia. Cyclothymia and its cousin hyperthymia are key to understanding and diagnosing all mood illnesses. Not only are those mood temperaments legitimate, but they deserve much more attention than they are receiving.



Akiskal HS, Mendlowicz MV, Jean-Louis G, Rapaport MH, Kelsoe JR, Gillin JC, Smith TL. TEMPS-A: validation of a short version of a self-rated instrument designed to measure variations in temperament. J Affect Disord, 2005; 85:45-52.

Ghaemi SN and Vohringer PA. Athanasios Koukopoulos' Psychiatry: The Primacy of Mania and the Limits of Antidepressants. Curr Neuropharmacol, 2017; 15:402-8.

Rihmer Z, Akiskal KK, Rihmer A, Akiskal HS. Current research on affective temperaments. Curr Opin Psychiatry, 2010; 23:12-18.

Vohringer PA, Whitham EA, Thommi SB, Holtzman NS, Khrad H, Ghaemi SN. Affective temperaments in clinical practice: a validation study in mood disorders. J Affect Disord, 2012; 136:577-80.


August 20, 2020