Cyclothymic Disorder

Cyclothymic disorder, or cyclothymia, is a form of bipolar disorder characterized by distinct episodes of hypomanic symptoms (elevated mood and euphoria) and depressive symptoms over a period of at least two years. The mood fluctuations are not sufficient in number, severity, or duration to meet the full criteria for a hypomanic or depressive episode, but they are present more than 50 percent of the time and no more than two months elapse without symptoms.

Hypomania involves periods of elevated mood, euphoria, and excitement but does not disconnect a person from reality. A person with cyclothymia experiences symptoms of hypomania but not full-blown manic episodes. Hypomania may feel good to the person who experiences it and may lead to enhanced functioning and productivity. Thus, even when family and friends learn to recognize the mood swings as a possible bipolar disorder, the person may deny that a problem exists. Without proper treatment, however, symptoms can worsen.

Approximately 0.4 percent to one percent of people will experience cyclothymia in their lifetime. The disorder usually begins in adolescence or early adulthood and it is lifelong. There is a 15 percent to 50 percent risk that a person with cyclothymic disorder will go on to develop bipolar I or bipolar II disorder, although many people do recover from cyclothymia and do not experience future symptoms of hypomania or depression. Cyclothymic disorder is equally common in males and females. It may co-occur with substance-use disorder or anxiety disorder. 

 

Symptoms

According to the DSM-5, cyclothymic disorder is manifest when, for at least two years (one year for children and adolescents), an individual displays periods of hypomanic symptoms and periods of depressive symptoms but the mood disturbances do not meet criteria for a hypomanic or major depressive episode. The mood fluctuations are present more than 50 percent of the time and the person is never symptom-free for more than two consecutive months. The symptoms are not the result of a medical condition or substance use. The condition usually has an insidious onset. 

Signs and symptoms of hypomania, as cataloged by the DSM-5:

  • A distinct period of abnormally and persistently elevated, expansive, or irritable mood 
  • An increase in goal-directed activity—sexually, socially, at work, or at school
  • Inflated self-esteem or grandiosity
  • Decreased need for sleep
  • Talkativeness
  • Racing thoughts, jumping from one idea to another
  • Distractibility, inability to concentrate
  • Excessive involvement in activities that have a high potential for painful consequences, , such as buying sprees, sexual indiscretions
  • The episode represents a distinct change in functioning and the changes in mood and behavior are observable by others..

Depressive symptoms include:

  • Persistent sadness
  • Fatigue or listlessness
  • Excessive sleepiness or, conversely, inability to sleep
  • Loss of appetite and weight loss or overeating and weight gain
  • Loss of self-esteem
  • Feelings of worthlessness, hopelessness, and/or guilt
  • Difficulty concentrating, remembering, or making decisions
  • Withdrawal from friends
  • Withdrawal from activities that were once enjoyed
  • Persistent thoughts of death

It is not uncommon for people with cyclothymic disorder to also have diagnoses of substance-related disorders and sleep disorders. Children with cyclothymic disorder are also more likely to have attention-deficit/hyperactivity disorder than other pediatric patients. 

Causes

The cause of cyclothymic disorder is unknown.

Hypomanic periods are energizing and can result in productivity for some people, while for others these periods can cause impulsive and callous behavior, which can damage relationships. Because hypomania feels good, people with cyclothymia may not seek treatment.

Current scientific evidence suggests there is no single cause of bipolar disorders—rather, many factors act together to produce these conditions. It is known, however, that major depressive disorder, bipolar I disorder, and bipolar II disorder are more common among close biological relatives of individuals with cyclothymic disorder. However, both genes and environmental factors play a role in bipolar disorder. 

 

Treatment

Treatment for cyclothymia is similar to treatment for bipolar I disorder and bipolar II disorder. The level of treatment is dependent on the severity of symptoms. 

Most people with bipolar disorder—even the most severe forms—can achieve substantial stabilization of their symptoms with proper treatment. Even in the most severe cases, bipolar disorders are highly treatable conditions. The sooner treatment begins, the greater the likelihood of reducing the severity and frequency of manic and depressive episodes. Because bipolar disorders are lifelong conditions, treatment is also lifelong and aimed not just at treating symptoms when they occur but also at preventing recurrence of symptoms. Most people with bipolar disorders can achieve substantial stabilization of their mood swings and related symptoms

The most effective treatment strategy combines medication and psychotherapy. In addition, patients are often instructed to keep a chart of daily mood symptoms, treatments, sleep patterns, and life events. Such tracking has been shown to help patients and their families to better understand and manage the illness; mood changes can often be spotted in time to prevent a full-blown episode. Even when there are no breaks in treatment, mood changes can occur and should be reported immediately to the doctor, who may make adjustments to the treatment plan. 

Medications

While primary-care physicians who do not specialize in psychiatry may prescribe psychotropic medications, it is recommended that people with bipolar disorder see a psychiatrist for treatment. Several types of medication are commonly used the treat bipolar disorders.

Mood stabilizers are generally prescribed to control manic episodes. Lithium is perhaps the best-known mood stabilizer. The first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, it is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes. Other types of mood stabilizers include the anticonvulsants lamotrigine (Lamictal), valproic acid (Depakene), divalproex sodium (Depakote), and carbemazepine (Tegretol and others). Valproate was FDA-approved in 1995 for the treatment of mania. 

Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect. Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression.

Sometimes treatment with antidepressants results in mood-switching, prompting a manic or hypomanic episode or rapid cycling. Mood-stabilizing medications generally are required, alone or in combination with antidepressants, to protect against such a switch.

Children and adolescents with bipolar disorder generally are treated with lithium, but valproate and carbamazepine are also used.

Women with bipolar disorder who wish to conceive or who become pregnant face special challenges due to possible effects of mood stabilizing medications on the developing fetus and the nursing infant. A skilled clinician can help such women weigh the benefits and risks of all available treatment options.

Antipsychotic medications are also often used to help control manic and depressive symptoms in bipolar disorder, and some help to stabilize mood as well. Antipsychotic drugs include olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal) among others.

If insomnia is a problem, a high-potency benzodiazepine medication such as clonazepam or lorazepam may be helpful. However, because these medications may be habit-forming, they are best prescribed short-term. Other types of sedative medications, such as zolpidem, are sometimes used instead.

Omega-3 fatty acids found in fish oil are under study for their usefulness, alone or when added to conventional medications, for long-term treatment of bipolar disorder.

Effective management of cyclothymia may involve changes to the treatment plan at various times over the course of illness. Any changes in type or dose of medication should be made under the guidance of a psychiatrist. To avoid adverse reactions, patients should tell the psychiatrist about all other prescription drugs, over-the-counter medications, or natural supplements they may be taking. 

People with a bipolar disorder, particularly those with rapid mood cycling, often have abnormal thyroid gland function. Because too much or too little thyroid hormone alone can lead to mood and energy changes, thyroid levels are usually carefully monitored by a physician. Lithium treatment may cause low thyroid levels in some people, resulting in the need for thyroid supplementation.

All medications have side effects. Depending on the medication, side effects may include weight gain, nausea, tremors, reduced sex drive, anxiety, hair loss, movement problems, or dry mouth.  Getting the right balance of treatment benefits may require a physician-monitored adjustment in dosage or type of medication. Medication should not be changed or stopped without the psychiatrist's guidance.

Psychotherapy

Studies have documented that several kinds of psychotherapy provided to patients and their families can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas. Psychotherapeutic interventions commonly used for bipolar disorder are cognitive behavioral therapy, psychoeducation, family therapy, and interpersonal and social rhythm therapy (IPSRT). IPSRT emphasizes the importance of establishing stable daily patterns of sleeping and waking, as prolonged wakefulness is a  known trigger for manic episodes.

A licensed psychologist, social worker, or counselor typically provides such therapies and often works in concert with the psychiatrist to monitor patient progress. Cognitive behavioral therapy (CBT) helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness.

Psychoeducation involves teaching people with bipolar disorder about the condition and its treatment and how to recognize signs of relapse so that early intervention can be sought before a full-blown episode occurs. Psychoeducation is also often helpful for family members.

Family therapy helps reduce the level of family distress that may contribute to or result from the ill person's symptoms.

Interpersonal and social rhythm therapy helps people with bipolar disorder both to improve relationships and to regulate daily routines. Maintaining a daily routine and sleep schedule can help protect against manic episodes.

References

  • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
  • Miklowitz, David. The Bipolar Disorder Survival Guide, Third Edition. 2019. Guilford Press, 444 pages.
  • National Institutes of Health
  • National Institutes of Mental Health, Genetics Workgroup  
  • US Public Heath Service, Office of Surgeon General

Last reviewed 02/07/2019