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Euthymia is defined as a normal, tranquil mental state or mood. It is often used to describe a stable mental state or mood in those affected with bipolar disorder that is neither manic nor depressive, yet is distinguishable from healthy controls. [23] Euthymia is also used to describe the “baseline” of other cyclic mood disorders like Major depressive disorder (MDD) and Narcissistic personality disorder (NPD), but this is not the true definition. Euthymia is often the basis on which bipolar disorder treatments are founded on. Treatment is tailored to bring patients back to their state of euthymia and therapy is often geared to a state of euthymia; it considered successful if it is able to bring the patient back to a state of euthymia. [2]

History

Euthymia is usually not defined by the appearance of symptoms, but rather is most often defined by the absence of mood symptoms. When a person no longer meets the threshold criterion for mania or depression, they are described as being in a euthymic state. The challenge that current research is faced with is working to create a positive and more comprehensive and detailed definition of euthymia. [2] The word ‘euthymia’ traces its roots to the Greek words eu, meaning well, and “thymo”, meaning soul or emotion. The word “thymos” also had four separate meanings; life energy; feelings and passions; will, desire, and inclinations; and thought or intelligence. Euthymia also stemmed from a verb, euthymeo, that meant both “I am happy, in good spirits” and “I make others happy, I reassure and encourage.” This is the basis on which the first formal definition of euthymia was built. Democritus said that the state of euthymia is when “one is satisfied with what is present and available, taking little heed of people who are envied and admired and observing the lives of those who suffer and yet endure”, This was later amended in the translation given to us by the Greek philosopher Seneca the Younger in which euthymia means a state of internal calm and contentment. Seneca was also the first to link the state of euthymia to a learning process; in order to achieve it, one must be aware of psychological well-being. Seneca’s definition also included a cache about detachment from current events. Later, the Greek biographer Plutarch, removed this cache with his definition which focused more on learning from adverse events. [2] In 1958, Marie Jodah gave a modern clinical definition of mental health in the terms of positive symptoms by outlining the criteria for mental health: "autonomy (regulation of behavior from within), environmental mastery, satisfactory interactions with other people and the milieu, the individual’s style and degree of growth, development or self-actualization, the attitudes of an individual toward his/her own self". In her definition she acknowledged the absence of disease as being necessary, but not enough, to constitute positive mental health, or euthymia. [2]

Measurment

For a long time there was no credible measurement of psychological well-being until American psychologist Carol Ryff, was the first to develop a comprehensive scale of what we know as euthymia when she developed the 84 item Six-factor Model of Psychological Well-being. [2] The scale included facets of self-acceptance, positive relations with others autonomy, environmental mastery, purpose in life, and personal growth. This scale, however, failed to include Jodah’s concept of flexibility. In facets of personality inventories like the Revised NEO Personality Inventory(NEO-PI), the definition of euthymia is broadened to encompass all of positive feeling or “well-being”. This broader definition is usually held in contrast to dysthymia, or “ill-being”. Disagreement about these definitions arises because the euthymia and dysthymia “subscales” do not meet the threshold for scalability in a Mokken scale analysis. Common NEO-PI euthymia items include such questions as “I am seldom sad or depressed.”, “I am pretty stable emotionally.”, and “I rarely feel fearful or anxious.” [21]

Criterion

If a person has a history of mood disorders, they must be in full remission of all symptoms to be in a state of euthymia. [1] If any sadness, anxiety, or other negative moods appear, they should only last for a short time before returning to normal levels and they should not affect everyday living. People in a state of euthymia are often happy, cheerful, calm, active, and interested in doing things. [2] They present a certain level of psychological flexibility, meaning they are able to adapt to new and changing situations. Additionally, they experience restful and restorative sleep. [2] However, increased feelings of impulsivity and emotional dysregulation, which are often seen during mania, have been found to persist during euthymia. [6]

Comparison to Healthy Controls

In bipolar patients during euthymia, in contrast to healthy control groups, there is a significant decrease in activation of the right ventrolateral prefrontal cortex in the brain during the process of emotional labeling, which is acknowledging and understanding an emotion based on physical and non-physical clues. There is a lack of consensus among researchers as to whether or not there is a deficit in emotion recognition during any phase of euthymia. There is greater connectivity between the right amygdala and the right ventrolateral prefrontal cortex in patients during euthymia in comparison to healthy controls. Because of this, people in a state of euthymia may experience greater motor control reactions in response to negative emotion stimulation such as fear, sadness, and anger [6]. Physiologically, bipolar patients in euthymia differ from typical healthy individuals in their brain structure. People in euthymia have significant grey matter reductions in their splenium (part of the corpus callosum), and right and anterior part of the insula, as well as abnormalities in their anterior cingulate cortex regions, which play a role in heart rate regulation and blood pressure, and white matter found in the prefrontal cortex, which can affect cognitive behavior, personality expression, decision making, and social behavior. This may help explain why there are often cognitive deficits between patients in eythymia and typical healthy people. There are also often anomalies in the hippocampus, the parahippocampal gyrus, which are essential for memory, and the caudate nucleus, which is important for motor function, although anomalies in the caudate nucleus are only prevalent in psychotic bipolar patients [13]. Another difference between healthy individuals and those in a state of euthymia in the production of morning serum cortisol. Serum cortisol shuts off the inhibitors of adrenal cortisol, allowing the stress response hormone to flow more freely. In female euthymic Bipolar 1 disorder patients, there is no significant difference in morning serum cortisol production from healthy controls. Conversely, in men, euthymic Bipolar 1 patients were categorized as having higher morning serum cortisol levels than healthy individuals. Euthymic male patients with Bipolar II also show elevated levels of morning serum cortisol from that of healthy people, while females do not show this elevation. [12]