What is cyclothymia

Cyclothymia also called cyclothymic disorder, is a rare mood disorder. Cyclothymia is classified as a mild form of bipolar disorder (manic depressive illness), in which a person has mood swings over a period of years that go from mild depression to emotional highs. Just like bipolar disorder, cyclothymia causes emotional ups and downs, but they’re not as extreme as those in bipolar I or II disorder. However the mood swings can affect daily life, and cause problems with personal and work relationships. It’s important you seek help managing these symptoms because they can interfere with your ability to function and increase your risk of progressing to bipolar I or II disorder.

The causes of cyclothymic disorder are unknown. Major depression, bipolar disorder, and cyclothymia often occur together in families. This suggests that these mood disorders share similar causes.

Cyclothymic disorder usually begins in adolescence or early adult life and is sometimes considered to reflect a temperamental predisposition to other disorders. In the general population, cyclothymic disorder is apparently equally common in males and females. Most people’s symptoms are mild enough that they don’t seek mental health treatment, or the emotional highs feel nice, so they don’t realize there’s anything wrong or want to seek help. This means cyclothymia often goes undiagnosed and untreated. In clinical settings, females with cyclothymic disorder may be more likely to present for treatment than males. If you think you have cyclothymia, it’s important to seek help from your doctor.

Cyclothymic disorder usually has an insidious onset and a persistent course. There is a 15%-50% risk that an individual with cyclothymic disorder will subsequently develop bipolar I disorder or bipolar II disorder, so it’s important to get help before reaching this later stage. Onset of persistent, fluctuating hypomanic and depressive symptoms late in adult life needs to be clearly differentiated from bipolar and related disorder due to another medical condition and depressive disorder due to another medical condition (e.g., multiple sclerosis) before the cyclothymic disorder diagnosis is assigned. Among children with cyclothymic disorder, the mean age at onset of symptoms is 6.5 years of age.

The lifetime prevalence of cyclothymic disorder is approximately 0.4%-1%. Prevalence in mood disorders clinics may range from 3% to 5%.

Treatment options for cyclothymia include talk therapy (psychotherapy), medications and close, ongoing follow-up with your doctor.

Cyclothymia outlook (prognosis)

Less than half of people with cyclothymic disorder go on to develop bipolar disorder. In other people, cyclothymia continues as a chronic condition or disappears with time.

Cyclothymia possible complications

Cyclothymia can progress to bipolar disorder.

Other possible compliactions of cyclothymia:

• Not treating it can result in significant emotional problems that affect every area of your life
• There is a high risk of later developing bipolar I or II disorder
• Substance abuse is common
• You may also have an anxiety disorder.

Cyclothymic Disorder DSM 5 Diagnostic Criteria

• A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.
• B. During the above 2-year period (1 year in children and adolescents) , the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.
• C. Criteria for a major depressive, manic, or hypomanic episode have never been met.
• D . The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
• E . The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
• F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

• With anxious distress

The essential feature of cyclothymic disorder is a chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms and periods of depressive symptoms that are distinct from each other (Criterion A). The hypomanic symptoms are of insufficient number, severity, pervasiveness, or duration to meet full criteria for a hypomanic episode, and the depressive symptoms are of insufficient number, severity, pervasiveness, or duration to meet full criteria for a major depressive episode. During the initial 2-year period (1 year for children or adolescents), the symptoms must be persistent (present more days than not), and any symptom-free intervals last no longer than 2 months (Criterion B). The diagnosis of cyclothymic disorder is made only if the criteria for a major depressive, manic, or hypomanic episode have never been met (Criterion C).

If an individual with cyclothymic disorder subsequently (i.e., after the initial 2 years in adults or 1 year in children or adolescents) experiences a major depressive, manic, or hypomanic episode, the diagnosis changes to major depressive disorder, bipolar I disorder, or other specified or unspecified bipolar and related disorder (subclassified as hypomanic episode without prior major depressive episode), respectively, and the cyclothymic disorder diagnosis is dropped.

The cyclothymic disorder diagnosis is not made if the pattern of mood swings is better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders (Criterion D), in which case the mood symptoms are considered associated features of the psychotic disorder. The mood disturbance must also not be attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism) (Criterion E). Although some individuals may function particularly well during some of the periods of hypomania, over the prolonged course of the disorder, there must be clinically significant distress or impairment in social, occupational, or other important areas of functioning as a result of the mood disturbance (Criterion F). The impairment may develop as a result of prolonged periods of cyclical, often unpredictable mood changes (e.g., the individual may be regarded as temperamental, moody, unpredictable, inconsistent, or unreliable).

Cyclothymia vs Bipolar

Cyclothymia (hypomania and mild depression) – cyclothymia or cyclothymic disorder is a milder form of bipolar disorder that consists of cyclical mood swings. However, the symptoms are less severe than full-blown mania or depression.

Bipolar disorder is a mental illness (once known as manic depression or manic-depressive disorder) that causes serious shifts in a person’s mood, energy levels, thinking, and behavior—from the highs of mania on one extreme, to the lows of depression on the other. More than just a fleeting good or bad mood, the cycles of bipolar disorder last for days, weeks, or months. And unlike ordinary mood swings, the mood changes of bipolar disorder are so intense and extreme that they interfere with your ability to function. These mood changes can be distressing for them and other people. They can affect how they live their life, and even put them in risky situations. Between these mood swings, however, they feel and act normally.

People with bipolar disorder have times when their highs are extreme and they have too much energy. These highs are called ‘mania’ when severe, or ‘hypomania’ when less severe. During a manic episode, you might impulsively quit your job, charge up huge amounts on credit cards, or feel rested after sleeping two hours. During a depressive episode, you might be too tired to get out of bed, and full of self-loathing and hopelessness over being unemployed and in debt.

Most people with bipolar disorder also have times when they feel extremely down. They can feel hopeless, helpless or empty. This is called bipolar depression.

In the past, bipolar disorder was called ‘manic depression’.

Bipolar disorder is a lifelong condition, but with the right treatment the symptoms can be well controlled.

While there is no cure for bipolar disorder, bipolar disorder can be treated effectively with medication and psychological treatment and the symptoms can be well controlled. This means many people with bipolar disorder can live full lives. Many people with bipolar disorder have responsible jobs and successful careers.

Types of bipolar disorder

There are four basic types of bipolar disorder with the main types being bipolar I disorder (bipolar one disorder) and bipolar II disorder (bipolar two disorder).

• People with bipolar I disorder have mania, and most also have depression.
• People with bipolar II disorder have hypomania and depression.
• Cyclothymic Disorder (also called cyclothymia)— defined by numerous periods of hypomanic symptoms as well numerous periods of depressive symptoms lasting for at least 2 years (1 year in children and adolescents). However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode.
• Other Specified and Unspecified Bipolar and Related Disorders— defined by bipolar disorder symptoms that do not match the three categories listed above.

Doctors use these categories to help them choose the right treatment.

The causes of bipolar disorder aren’t completely understood, but it often appears to be hereditary. The first manic or depressive episode of bipolar disorder usually occurs in the teenage years or early adulthood.

• Around 1 in every 100 people will have bipolar disorder (I or II) during their life.
• It is seen in males and females, and in all countries and cultures.
• For people with bipolar I, symptoms usually begin during their late teens, with depression.
• For bipolar II, symptoms tend to start later, when the person is in their late 20s.

The symptoms can be subtle and confusing; many people with bipolar disorder are overlooked or misdiagnosed—resulting in unnecessary suffering. But with proper treatment, self-help, and support, you can function normally and lead a rich and fulfilling life.

Symptoms of bipolar disorder

People with bipolar disorder have extreme highs (mania or hypomania) and most also have lows (bipolar depression).

Different people have these in different combinations. For example, people can have:

• mostly mania/hypomania
• mostly depression
• depression followed by mania/hypomania
• features of both at the same time (this is called ‘mixed states’).

Between these mood swings, however, they feel and act normally.

People with bipolar disorder usually have depression for much more of the time than they have mania or hypomania.

Bipolar is different for everyone, but a common pattern is that someone will have at least one episode of bipolar symptoms every few years, with each episode lasting for a few months.

Some people have ‘rapid cycling’ bipolar, which means they have at least 4 episodes per year. Mood swings can occur very quickly, like a rollercoaster randomly moving from high to low and back again over a period of days or even hours. Rapid cycling can leave you feeling dangerously out of control and most commonly occurs if your bipolar disorder symptoms are not being adequately treated.

Treatments for bipolar disorder include:

• medications for mania, hypomania and depression
• medication to stop symptoms returning
• psychological treatments (talking therapies).

In some circumstances, electroconvulsive therapy (ECT) might be recommended.

Cyclothymia causes

The causes of cyclothymia aren’t known, but there’s probably a genetic link because cyclothymia, depression and bipolar disorder all tend to run in families.

In some people, traumatic events or experiences may act as a trigger for the condition, such as severe illness or long periods of stress.

As with many mental health disorders, research shows that it may result from a combination of:

• Heredity, as cyclothymia tends to run in families
• Your body’s biochemical processes, such as changes in brain chemistry
• Environment, such as traumatic experiences or prolonged periods of stress.

Risk factors for developing cyclothymia

Cyclothymia is thought to be relatively rare. But true estimates are hard to pin down because people may be undiagnosed or misdiagnosed as having other mood disorders, such as depression.

Cyclothymia typically starts during the teenage years or young adulthood. It affects about the same number of males and females.

Cyclothymia prevention

There’s no sure way to prevent cyclothymia. However, treatment at the earliest indication of a mental health disorder can help prevent cyclothymia from worsening. Long-term preventive treatment also can help prevent minor symptoms from becoming full-blown episodes of hypomania, mania or major depression.

Cyclothymic disorder symptoms

If you have cyclothymia, you’ll have periods of feeling low followed by periods of extreme happiness and excitement (called hypomania) when you don’t need much sleep and feel that you have a lot of energy.

The periods of low mood don’t last long enough and aren’t severe enough to be diagnosed as clinical depression.

You might feel sluggish and lose interest in things during these periods, but this shouldn’t stop you going about your day-to-day life.

Mood swings will be fairly frequent – you won’t go for longer than 2 months without experiencing low mood or an emotional high.

Symptoms of cyclothymia aren’t severe enough for you to be diagnosed with bipolar disorder, and your mood swings will be broken up by periods of normal mood.

Cyclothymia symptoms may include any of the following:

• Periods (episodes) of extreme happiness and high activity or energy (mania), or low mood, activity, or energy (depression) for at least 2 years (1 or more years in children and adolescents)
• Mood swings (these are less severe than in bipolar disorder or major depression)
• Ongoing symptoms, with no more than 2 symptom-free months in a row

Hypomanic symptoms

Signs and symptoms of the highs of cyclothymia may include:

• An exaggerated feeling of happiness or well-being (euphoria)
• Extreme optimism
• Inflated self-esteem
• Talking more than usual
• Poor judgment that can result in risky behavior or unwise choices
• Racing thoughts
• Irritable or agitated behavior
• Excessive physical activity
• Increased drive to perform or achieve goals (sexual, work related or social)
• Decreased need for sleep
• Tendency to be easily distracted
• Inability to concentrate

Depressive symptoms

Signs and symptoms of the lows of cyclothymia may include:

• Feeling sad, hopeless or empty
• Tearfulness
• Irritability, especially in children and teenagers
• Loss of interest in activities once considered enjoyable
• Changes in weight
• Feelings of worthlessness or guilt
• Sleep problems
• Restlessness
• Fatigue or feeling slowed down
• Problems concentrating
• Thinking of death or suicide.

Cyclothymic disorder diagnosis

The diagnosis is usually based on your mood history. Your health care provider may order blood and urine tests to rule out medical causes of mood swings.

Your doctor or other health care provider must determine if you have cyclothymia, bipolar I or II disorder, depression, or another condition that may be causing your symptoms.

To help pinpoint a diagnosis for your symptoms, you’ll likely have several exams andcyclothymia tests, which generally include:

• Physical exam. A physical exam and lab tests may be done to help identify any medical problems that could be causing your symptoms.
• Psychological evaluation. A doctor or mental health provider will talk to you about your thoughts, feelings and behavior patterns. You may also fill out a psychological self-assessment or questionnaire. With your permission, family members or close friends may be asked to provide information about your symptoms, such as possible hypomanic or depressive symptoms.
• Mood charting. To identify what’s going on, your doctor may have you keep a daily record of your moods, sleep patterns or other factors that could help with diagnosis and finding the right treatment.

Cyclothymia DSM 5

For a diagnosis of cyclothymia, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists these points:

• You’ve had many periods of elevated mood (hypomanic symptoms) and periods of depressive symptoms for at least two years (one year for children and teenagers) — with these highs and lows occurring during at least half that time.
• Periods of stable moods usually last less than two months.
• Your symptoms significantly affect you socially, at work, at school or in other important areas.
• Your symptoms don’t meet the criteria for bipolar disorder, major depression or another mental disorder.
• Your symptoms aren’t caused by substance use or a medical condition.

Cyclothymia treatment

Cyclothymia requires lifelong treatment — even during periods when you feel better — usually guided by a mental health provider skilled in treating the condition.

To treat cyclothymia, your doctor or mental health provider aims to:

• Decrease your risk of bipolar I or II disorder, because cyclothymia carries a high risk of developing into bipolar disorder
• Reduce the frequency and severity of your symptoms, allowing you to live a more balanced and enjoyable life
• Prevent a relapse of symptoms, through continued treatment during periods of remission (maintenance treatment)
• Treat alcohol or other substance use problems, since they can worsen cyclothymia symptoms

Treatments for this disorder include mood-stabilizing medicine, antidepressants, talk therapy, or some combination of these three treatments.

Some of the more commonly used mood stabilizers are lithium and antiseizure medicines.

The aim is to:

• stop the cyclothymia developing into bipolar disorder
• reduce your symptoms
• stop your symptoms coming back

You’ll probably need to continue this treatment for the rest of your life.

Some people with cyclothymia may not respond to medicines as well as people with bipolar disorder.

Medications

No medications are approved by the Food and Drug Administration specifically for cyclothymia, but your doctor may prescribe medications used to treat bipolar disorder. These medications may help control cyclothymia symptoms and prevent periods of hypomanic and depressive symptoms.

You may be prescribed:

• medications to level out your mood (mood stabilizers)
• antidepressants

Mood stabilizers include:

• lithium – commonly used to treat bipolar disorder
• anti-epileptic drugs – such as carbamazepine, oxcarbazepine or sodium valproate

Antidepressants may help improve your low moods, but they may cause you to switch to the other extreme of hypomania.

Recently, some antipsychotics such as quetiapine have also been used as mood stabilizers.

But not all people with cyclothymia respond to medication.

What are mood stabilizers?

Mood stabilisers are psychiatric drugs that are licensed as part of the long-term treatment for:

• bipolar disorder (manic depression)
• mania and hypomania
• sometimes recurrent severe depression

Some of the individual drugs we call mood stabilizers are actually very different chemical substances from each other. But health care professionals often group them together, because they can all help to stabilize your mood if you experience problems with extreme highs, extreme lows, or mood swings between extreme highs and lows.

Which drugs are mood stabilizers?

The 5 individual drugs that can be used as mood stabilizers are:

• lithium (Camcolit, Liskonum, Priadel, Lithonate, Litarex, Li-liquid)
• carbamazepine (Tegretol)
• lamotrigine (Lamictal)
• valproate (Depakote, Epilim)
• asenapine (Sycrest)

What kind of substances are they?

• Lithium

Natural mineral – lithium is actually an element that occurs naturally in the environment, not a manufactured drug.

• Carbamazapine, lamotrigine and valproate

Anticonvulsants – these 3 drugs are actually anticonvulsant medication (also known as antiepileptic medication), which were all originally made for treating epilepsy. Epilepsy is a neurological disorder that can cause seizures.

• Asenapine

Antipsychotic – asenepine is actually an antipsychotic drug, but it is usually only used as a mood stabilizer.

Which mood stabilizer is right for me?

The drugs that can be prescribed as mood stabilizers have different potential advantages and disadvantages. For example:

• Lithium can be a very effective treatment for mania, but is less effective at treating severe depression. You might be offered lithium if you have a diagnosis of bipolar I (characterised by manic episodes).
• Carbamazepine (Tegretol) and valproate (Depakote, Epilim) are comparatively effective in treating:
  • mixed episodes of mania and depression (feeling low and high at the same time)
  • rapid cycling between mania and depression
  • very severe mania with psychosis
  • additional anxiety disorders or substance abuse
  • symptoms that occur after neurological illness or brain injury
  • people who have little or no family history of bipolar disorder
• Lamotrigine (Lamictal) has antidepressant effects and is licensed to treat severe depression in bipolar disorder. You might be offered lamotrigine if you have a diagnosis of bipolar II (characterised by severe depressive episodes alternating with hypomania).
• Asenapine (Sycrest) is specifically licensed to treat mania in bipolar disorder. You might be offered asenapine if other mood stabilisers aren’t right for you.

Depending on your diagnosis and the problems you experience, your doctor might suggest that a combination of a mood stabiliser and another drug might be the best way to manage your symptoms. In this case, they might decide to offer you other kinds of medication as part of your treatment, such as:

• certain antipsychotic drugs – for example, the antipsychotics licensed to treat mania are: aripiprazole (Abilify); olanzapine (Zyprexa); quetiapine (Seroquel); and risperidone (Risperdal)
• certain antidepressants
• benzodiazepine tranquillisers

Psychotherapy

Psychotherapy, also called psychological counseling or talk therapy, is a vital part of cyclothymia treatment and can be provided in individual, family or group settings.

Psychotherapy, such as cognitive behavioral therapy (CBT), can help with cyclothymia.

Cognitive behavioral therapy (CBT) involves talking to a trained therapist to find ways to help you manage your symptoms by changing the way you think and behave.

You’ll be given practical ways to improve your state of mind on a daily basis.

• Cognitive behavioral therapy (CBT). A common treatment for cyclothymia, the focus of cognitive behavioral therapy is to identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones. It can help identify what triggers your symptoms. You also learn effective strategies to manage stress and cope with upsetting situations.
• Interpersonal and social rhythm therapy. Interpersonal and social rhythm therapy focuses on the stabilization of daily rhythms, such as sleep, wake and mealtimes. A consistent routine allows for better mood management. People with mood disorders may benefit from establishing a daily routine for sleep, diet and exercise.
• Other therapies. Other therapies have been studied with some evidence of success. Ask your doctor if any other options may be appropriate for you.

Support Groups

You can ease the stress of living with cyclothymic disorder by joining a support group whose members share common experiences and problems.

Living with cyclothymia

It’s not known how many people with cyclothymia will go on to develop bipolar disorder.

But some people with cyclothymia see their elevated or depressed moods become more severe.

Other people will find their cyclothymia continues and they need to manage this as a lifelong condition, or that it disappears with time.

Coping and support

Coping with cyclothymia can be difficult. During periods when you feel better, or during hypomanic symptoms, you may be tempted to stop treatment. Here are some ways to cope with cyclothymia:

• Learn about the disorder. Learning about cyclothymia and its possible complications can empower you and motivate you to stick to your treatment plan. Also, help educate your family and friends about what you’re going through.
• Join a support group. Ask your provider if there’s any type of support group that might help you reach out to others facing similar challenges.
• Stay focused on your goals. Successfully managing cyclothymia can take time. Stay motivated by keeping your goals in mind.
• Find healthy outlets. Explore healthy ways to channel your energy, such as hobbies, exercise and recreational activities.
• Learn relaxation and stress management. Try relaxation methods or stress-reduction techniques such as meditation, yoga or tai chi.

Lifestyle and home remedies

In addition to professional treatment, you can build on your treatment plan by following these lifestyle and self-care steps:

• Take your medications as directed. Even if you’re feeling well, resist any temptation to skip your medications. If you stop, cyclothymia symptoms are likely to come back.
• Pay attention to warning signs. You may have identified a pattern to your cyclothymia symptoms and what triggers them. Follow your treatment plan if you feel you’re facing a period of high or low symptoms. Involve family members or friends in watching for warning signs. Addressing symptoms early may keep them from getting worse.
• Quit drinking or using recreational drugs. Alcohol and recreational drugs may trigger mood changes. Talk to your doctor if you have trouble quitting on your own.
• Check first before taking other medications. Call the doctor who’s treating you for cyclothymia before you take over-the-counter medications or medications prescribed by another doctor. Sometimes other medications trigger periods of cyclothymia or may interfere with medications you’re already taking.
• Keep a record. Track your moods, daily routines and significant life events. These records may help you and your mental health provider understand the effect of treatments and identify thinking patterns and behaviors associated with cyclothymia symptoms.
• Get regular physical activity and exercise. Moderate, regular physical activity and exercise can help steady your mood. Working out releases brain chemicals that make you feel good (endorphins), can help you sleep and has a number of other benefits. Check with your doctor before starting any exercise program.
• Get plenty of sleep. Don’t stay up all night. Instead, get plenty of sleep. Sleeping enough is an important part of managing your mood. If you have trouble sleeping, talk to your doctor or mental health provider about what you can do.